World Health

Organization

Assessment of

Sustainability:

SWII CDTI Project,

Cameroon (8th Year)

April 13-28, 2008

Joseph C. OKEIBUNOR

& Daniel EBAH Germaine EKOYOL EWANE

Chinyere MADUKA Bambo Emmanuel NGALA Daniel YOTA

African Programme for Onchocerciasis Control

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Acknowledgements

We are grateful to the following persons and organisations for their cooperation, contributions and assistance towards the successful execution of this assignment

ƒ The Director, Dr. U. Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment ƒ The WR, Cameroon and WHO staff provided support, which contributed to the smooth functioning of the Evaluation Team ƒ Dr Ntep, National Onchocerciasis Project Coordinator, and her team facilitated the smooth take off of the exercise in Cameroon ƒ The Delegate and staff of the Southwest Provincial Delegation for Public Health for facilitating the conduct of the evaluation and providing relevant information ƒ The District Medical Officers and the teams who provided useful information ƒ Health workers and community members in the health areas who provided important information and contributed to the success of the mission ƒ Last but not least is our immense gratitude to the team of accommodating drivers who drove the Evaluation Team over several kilometres of very demanding roads and terrain under tough conditions

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Abbreviations/Acronyms

4WD Four Wheel Drive

APOC African Programme for Onchocerciasis Control

CBAF Chief of Bureau of Administration and Finance

CBH Chief of Bureau Health

CDD Community Directed Distributor of Mectizan®

CDTI Community Directed Treatment with Ivermectin

CR Country Representative

DHS District Health Service

DMO District Medical officer

DO District Officer

HA Health Area

HIPC Highly Indebted Poor Countries

HSAM Health Education, Sensitization, Advocacy and Mobilization

MDP Mectizan® Donation Programme

MEDP Manager, Essential Drug Programme

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MOH Ministry of Health

NGDO Non-Governmental Development Organization

NOTF National Onchocerciasis Task Force

OPC Onchocerciasis Programme Coordinator

PCGS Provincial Chief of General Service

PCSAFA Provincial Chief of Service for Administration and Financial Affairs

PCSME Provincial Chief of Unit – Supervision, Monitoring and Evaluation

PCSP Provincial Chief of Service for Pharmacy

PDPH Provincial Delegation of Public Health

SAE Severe Adverse Effect

SDO Senior District Officer

SSI Sight Savers International

SQI Systemic Quality Improvement

SWII Southwest II

SWAP Sector Wide Approach

SWPDP South West Province Drug Programme

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SWPSFH South West Province Special Fund for Health

TB Tuberculosis WHO World Health Organization

WR World Health Organization Country Representative

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Executive summary

Introduction

The Southwest II CDTI project is the second CDTI project in Southwest Province of Cameroon, with administrative headquarters in Buea. It covers eight health Districts, not covered under the SWI CDTI project in the same Provincial Area of Cameroon. The SWII CDTI project has been supported by APOC since 2000 and is on its eighth year of community mass treatment with Mectizan® with APOC funding support. The mid-term evaluation of the project was carried out between April 21st and May 7th 2003. The results of the mid term evaluation identified lapses in the implementation of the programme and concluded that the project was not making satisfactory progress towards sustainability. Remedial steps were recommended. Summary of the 2003 evaluation findings are contained in the box 1 below.

Box 1: Précis of 2003 Evaluation Results

In 2003 the SWII CDTI project progress towards sustainability was adjudged unsatisfactory given the various short comings in its operation. Quantitatively, the project earned 2.17 points which was far below the 2.5 points benchmark for satisfactory performance. It was scored low on almost every group of indicators, with the exception of planning, Training/HSAM and human resources 2.88, 2.73 and 2.68 points respectively. The project scored <2.00 points on finance, transport, integration and coverage respectively.

The Provincial/project level was the weakest with 1.92 points. Leadership, an indication of ownership of the project, was non existent here. The NGDO was overbearing and the project was seen as SSI project. SSI directed the implementation of the project generally. Leadership and political commitments were weak. The FLHF level was tops with 2.64 points. The other levels, community and District scored 2.00 and 2.11 points respectively.

The evaluation team found serious barriers to sustainability and concluded that the project would require rethinking of the roles of partners as well as appropriate and carefully targeted HSAM to inject the right sense of ownership of the programme at the appropriate levels (Project and communities) as well as mobilize sufficient support for the sustainability of CDTI post-APOC.

Community ownership, uncomplicated and reliable Mectizan® supply system and leadership role of government partners at all levels and community were lacking in the project. These deficiencies were identified to be seriously block sustainability in the project.

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Constitution and Task of 2008 Evaluation Team

Five years later APOC constituted another team of evaluators from Nigeria and Cameroon with the mandates of re-evaluating the sustainability performance of the project and supporting the implementers of the SWII CDTI project in developing sustainability plans. The tasks were undertaken between the 13 and 28 April 2008.

The evaluation in the field was carried out over a period of one week. During this period, information were gathered from desk review of relevant documents and reports, interviews with implementers and key stakeholders as well as field observation of CDTI implementation activities in sampled sites at the Provincial, District, First Line Health Facility and village levels. Focus group discussions were also held with community members. This was followed by a one day feedback session and a two-day workshop for the development of a five-year sustainability plan by those responsible for the project implementation at the Provincial and District Levels. The collation and analysis of information garnered from the field evaluation of CDTI activities in the SWII project area and planning of the feedback and sustainability planning workshops took three days of intense work by the evaluators.

At the end of the feedback and sustainability planning workshop, the teams came up with draft plans which the District and Provincial level staff were asked to home, edit and make necessary corrections and forward copies duly signed by the appropriate authorities to APOC management in Ouagadougou. Meanwhile the evaluation team took the remaining days to revisit its evaluation findings employing the new facts from the feedback session to fine tune its conclusions. It must be noted at his point that the feed back session provided a valuable opportunity to meet a wider spectrum of participants in the implementation of the CDTI project. For instance, only three of the eight health districts were visited during the field evaluation. The remaining five health district staff members were met during the feedback meeting. They reflected on the findings and drew lines from the findings with happenings in their respective health districts. These new pieces of information, consider vital in getting broader pictures of issues in the project was duly recognized and integrated into the conclusions on issues within the SWII project area.

Findings from 2008 Evaluation

Every village that was identified as qualified for mass treatment with Mectizan® is receiving it, except 12 of the 15 villages in Ogurah health area, where treatment is currently not being carried out because of the co-endemicity of onchocerciasis and loa loa. Therapeutic coverage for the project for the last three treatment periods (2005-2007) is >65 percent. Therapeutic coverage for 2005, 2006 and 2007 was 72.9 percent, 75.1 percent and 76.2 percent respectively. It showed that coverage has been on a steady increase.

There is convincing evidence that Mectizan® treatment is becoming part of the culture of people of the different villages and they expressed willingness to continue with treatment for as long as it is offered. The people are beginning to demand Mectizan®. Even where CDDs refuse to distribute Mectizan® in protest against lack of motivation, the people walk to the health centers to demand and swallow Mectizan®. In one of the communities in Mamfe Health District, a woman gave Mectizan® to a two year old baby, believing that the wonder drug

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(Mectizan®) cures every illness. Unfortunately the baby died. The DMO is planning HSAM activities to address this wrong use of Mectizan® as well as the negative campaign that may follow the death of the baby. Beyond that however, community members associated Mectizan® with a number of other correct health and social benefits. One striking benefit mentioned by a community leader is that “Mectizan® makes you so strong that when you are beaten by rain during farm work your skin does not get soaked “.

However, communities have not been empowered to play a leading role in CDTI implementation at the local level. They are not empowered to take decisions on the timing of distribution and in some cases selection of CDDs. More importantly they are not empowered to take decisions on ways of supporting or caring for the CDDs. Instead Government decided to, and pays CDDs for distributing Mectizan® in the communities.

The current community satisfaction with CDTI has the potential for creating demand for continuation of the programme, community ownership and support for distribution of Mectizan® and thus enhancing sustainability. This has not been exploited. At community level, measures to enhance sustainability of the CDTI programme are yet not implemented.

CDDs were willing to continue because the tablet is helping them and their people. However, some CDDs complained of the non-payment of government’s promised compensation for the last two distributions (2006 and 2007). Some threaten to discontinue distribution of Mectizan® or participating in any health activities, such as Polio eradication programme, if not paid. Others, however, request external bodies to sensitize the communities on the fact that this is a voluntary assignment where no one is paid so that the CDDs could be recognized as rendering altruistic services to their communities. Structures exist in the communities to support the CDTI process in the communities. For instance the village health committee is the highest dialogue structure on health matters in the communities. Some district health services are beginning to explore ways of integrating the CDTI programme into the mandate of the village health committees and by so doing resolve the dilemma of CDD compensation. A few communities are beginning to make arrangements to pay CDDs and prevent disruption in distribution of Mectizan®. The Evaluation Team concludes that CDTI at the village level is making satisfactory progress towards sustainability and will become sustainable, provided appropriate and adequate support continues to be provided by the higher levels and communities are sensitized to play their roles in CDTI.

There is high-level political commitment as evidenced in the involvement of some key members of the Southwest Provincial Delegation of Public Health in the campaign for Mectizan® distribution. Contrary to the practice in 2003, the leaders here have assumed full leadership roles in the implementation of the programme. They no longer wait for the NGDO to push and direct them on what to do. The team now plans, initiates and undertakes CDTI activities. The leadership at the Provincial level is very much aware of the problems and progress in the project and plans are made to address the problems such as CDD compensation, relatively low coverage in some health areas and communities and the fear of severe side effects in areas with loa loa. The District teams however still wait to be pushed.

The staff attitude, commitment and level of supervision are satisfactory though training is a routine activity with no objective need to be addressed at the Health Area level. The SWII

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CDTI implementation team conducts HSAM when it is deemed necessary. All the same some key stake holders demonstrated poor knowledge of CDTI implementation at the Provincial level. It was noted that no HSAM activities were undertaken at the Provincial level. The team considered it unnecessary because the information media in Buea do not get to the target communities covered under the SWII CDTI project. However, the critical and key stakeholders, such as the Provincial Governor knows nothing about the SWII CDTI project. Worse still, HSAM at the community level has not been effective because many community leaders interviewed pleaded ignorance on the roles of the communities in CDTI. In some, the community leaders are neither targeted with information nor involved in resolving problems facing the implementation of CDTI in their domain.

Government funding for CDTI at Provincial and District levels has improved from what it was prior to the 2003 evaluation. Before 2003, Government did not make disbursements for CDTI field activities. Between 2003 and 2008 Government spent various amounts in support of CDTI implementation in the project area. These government funding supports was categorized into direct and indirect. As a direct funding, the MoH spent $28,268.00 on the SWII CDTI project. However this money went mainly for payment of compensation to CDDs for the distribution of Mectizan®. In addition to this, Government paid salaries of the health staff and made provision for stationeries, transport and other logistics requirements for the implementation of CDTI within the SWII CDTI project area. Part of the indirect funding is the provision of running credit, for the health centers, which are sometimes used for CDTI field activities like submission of reports. This comes as a reflection of the integrated use of resources in the health service. It has also made other indirect funding of the SWII project through NOTF supports for supervision. Between 2004 and 2008 NOTF disbursed $1,683.00 to help the project coordinator with supervision. The Southwest Provincial Delegation of Public Health maintains the capital equipment and vehicles and had spent $6,047 on the maintenance of CDTI 4WD Hilux double cabin pickup van between 2005 and 2008.

All the same the major funding for CDTI is from external sources, specifically APOC and SSI. Between 2001 and 2008, SSI provided technical and financial support of about $372,938.00 and still plans to give another $197,115.39 for the coming four years (2009-2012). APOC, on the other hand, has committed $534,035.00 along with other technical assistance to the project since inception.

The evaluators were of the view that although government is now disbursing funds for CDTI activities, the funds are wrongly channeled to CDD compensation which should be the responsibility of the communities. Worse still the amounts is not increasing proportionately to the decline in external funding. Nothing is done to bridge shortfalls in funding for CDTI implementation.

Again, the project finance officer was not a government staff. He was paid and supported by SSI though in response to the recommendations of the evaluation team in 2003 he was relocated to the Provincial Delegation of Public Health in Buea. All the same he was not answerable to the authorities in the Delegation and the Political head here could not explain his where about during the evaluation. The Delegate however blamed this on the entire set up. According to him, this is not peculiar to CDTI. Vertical implementation of project activities and of course fund management is a fundamental problem in health care delivery system in

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Cameroon, which the government is now trying to address with the sector wide approach (SWAP) in planning, budgeting and programme execution.

Still in response to the recommendation of the 2003 evaluation, the process of accessing APOC funds has been greatly simplified. Now the CDTI implementation team at the provincial level simply initiates demand for funds which is authorized by the Delegate. This order goes to SSI in Yaoundẻ. It returns ready to be cashed in Buea.

All the same there are sufficient funds to carry out target activities and the funds are efficiently managed. Albeit, these funds were from APOC and SSI and relatively very little was from Government. However, it is important to note that the Government is planning on pooling resources in a common basket, which is hoped to make funds available for implementation of CDTI support activities at this level and the levels immediately below (District and Health Areas). The current financial position of the project, with respect to government contribution is considered to be blocking sustainability. If the resources used in paying CDDs are channeled to support activities of the health service while communities are sufficiently sensitized to assume their roles in CDTI, which includes supporting CDDs, there will be enough funds for CDTI activities at all levels. This will be further strengthened with the planned sector wide approach in budgeting, integrating funds and activities of programmes in each sector.

The evaluation team noted the availability of transport for the implementation of CDTI activities. The Delegation also maintains transport, although maintenance of vehicles is only when they break down or when they are needed for a particular activity such as polio campaign. There is no planned preventive maintenance of vehicles in the Delegation, except for the new Hilux Pickup the Government gave the Delegate recently. Worse still, there is no plan for replacement of these vehicles when they become dysfunctional. At the lower levels, transport facilities are non existent in some health districts. Where vehicles exist, they are poorly controlled though used for the implementation of all health activities. The health system does not meet the maintenance cost for the vehicles. The officers maintain and use the vehicles for non health issues.

With respect to Mectizan®, there is sufficient Mectizan® every year. However, in 2008 Mectizan® arrived late due to late ordering. The Project and NOTF are thinking seriously on ways of averting a reoccurrence of such lateness in future. It is important to note however, that in response to the recommendations of the 2003 evaluation, the procurement and management of Mectizan® are integrated into the government system used by the provincial drug programme. This system is simple and effective.

In evaluating the project on the basis of the seven aspects and five critical elements of sustainability, the Evaluation Team concludes that the SWII CDTI is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY.

With regard to the five critical elements the Evaluation Team found that three (supervision, Mectizan® and political commitment) were present in the project. The elements of money and transport were not satisfactory in the project. The resources were mainly from outside though there are opportunities for increased government funding.

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With respect to the seven aspects of sustainability, the Evaluation Team found that five, namely integration, efficiency, simplicity, attitude of staff, and effectiveness were very much helping sustainability of the project. However, resources and community ownership were found to be blocking sustainability because government funding and provision of both capital and consumable materials for the programme are very minimal. The project is, indeed, over dependent on non-Government sources for resources. Furthermore, ownership of the programme at the community level is lacking.

All the same, the quantitative score of 2.85 shows that the project is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY and would continue to progress if the remedial actions recommended by the Evaluation Team are taken.

There were also clear indications of the implementation of the recommendations of the 2003 evaluation team. One of such indications was the relocation of the project finance officer from Yaoundẻ to Buea. Others include the simplification of the process of accessing funds for supporting CDTI activities as well as the separation of APOC and SSI accounts. Furthermore, the accounts are now operated in Buea. These went a long way to improving the leadership and ownership of the project among the policy makers in the Delegation.

During the feed back meeting, the Delegate and other members of the SWII CDTI project lauded the findings as apt and eye opener. It was noted that some of these facts in the evaluation findings were taken for granted but however acknowledged the leading role of APOC CDTI programme in pointing out errors and positing realistic remedies. “APOC leads the way always. It does not only bring us closer to the communities but shows us how to do things better”.

From this point and mindset the team proceeded to develop a five year sustainability plan with the evaluation finding and recommendations in mind and to address the weaknesses observed in the project. The team also discussed ways of moving the project forward. Some of the ideas on the way forward are listed hereunder.

Way Forward

As the SWII CDTI project in Cameroon moves over the period for APOC-guaranteed support the team of evaluators and the ‘programme managers’ made a critical appraisal of the issues that need to be addressed in the short- and medium-terms to ensure the sustainability of the project post-APOC. The following is a summary of the highlights of the seven critical components of the “way forward” outlined at the joint final session between the external evaluators and the operators of the SWII CDTI project.

1. Documentation: An important area of deficiency that needs to be tackled in order to enhance the sustainability of CDTI is the relative lack of expertise in report writing by the various operators at the lower levels in the project. This is with special reference to documentation of government contribution to the project implementation. A series of workshops at the level of the Districts and Health Areas that address this shortcoming is highly desirable.

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2. Resource Mobilization: By mutual agreement the contribution of the various stakeholders to the sustenance of the SWII project post-APOC is a major challenge. It was agreed that the Provincial and District Teams should take advantage of the SWAP to plan and provide resources, both financial and material for the sustainable implementation of the project. The commitment of all to this element of the programme was emphasised and would be given appropriate prominence in the post-APOC plan of operations. Further to this, the SSI has undertaken to train the implementers on strategies for resource mobilization to reduce dependence on donor funds

3. HSAM: In recognition of the poor sense of ownership of the project at the community level, it was resolved that high powered HSAM activities supported by staff from the District and Provincial levels should be undertaken to sensitize the community members on their roles in CDTI. The need for intensification of HSAM is further strengthened by the surrounding Mectizan® in the Ogurah Health Area of Eyumujock. The area is endemic of loa loa and onchocerciasis. The strong fear of side effect makes it difficult for the people to receive treatment. The result is that only 3 of the 15 communities that should be receiving treatment in the Ogurah health area do that now.

4. CDD Compensation: There was a mutual agreement on the dangers of the current practice where Government pays CDDs for distributing Mectizan® in their communities. This was seen as a threat to sustainability of the project. To address this imminent threat, it was agreed that steps should be taken to sensitize government on its roles in CDTI and re-channel such funds to supporting the activities at the Provincial and District/Health Area levels, while the communities are sensitized to take on their responsibility of supporting the CDDs.

5. Re-orientation of Health Staff: Following the observation of the evaluation team on the dissatisfaction of some health staff at the District and Health Area levels following the withdrawal of APOC allowances, it was thought fit to undertake a re-orientation of the health staff on the APOC philosophy as well as train new health workers in the new created Health Districts on APOC philosophy and CDTI strategy. The complaints against the withdrawal of APOC allowances are a clear indication of poor understanding of the APOC philosophy among some health staff. This needs to be addressed in the short term to ensure the proper implementation of the plans for sustainability of the SWII CDTI project.

6. Recruitment of a Government Staff and Project Finance Officer: It was also agreed that the Delegation should assign one of its staff as the project finance officer. The old practice where SSI recruited and paid the salaries of the project finance officer mere sustains the rejected principle and practice of vertical programming within the public health system. Such a finance officer naturally would not be answerable to the leadership of the Delegation. This also negates the principle of ownership of the project within the Delegation which it is meant to serve.

7. Operations Research: The evaluation team also found the new enthusiasm to take Mectizan® very interesting in many respects and the same time awesome. The low CDD dropout rate, contradicts to what is seen elsewhere. Many CDDs expressed willingness to continue to distribute Mectizan®, irrespective of Government’s failure to

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pay the CDDs every year as promised, because they consider their service to their communities more valuable than any pay. These need to be systematically documented and to serve as reference materials for promoting community ownership. It is reasoned that if these are real there are lessons to be learn from them. Thus both the evaluation and SWII CDTI implementation teams discussed and agreed that it will be rewarding to conduct one or two operation researches to ascertain the factors driving the zeal in the CDDs to continue to distribute Mectizan and the willingness of the people to continue to take Mectizan®. The questions for the CDD study will include

a. To what extent is their willingness to distribute Mectizan® driven by altruistic motives? b. What is the link between CDD willingness to distribute Mectizan® and the current practice where government pays them for their roles every year? c. What is influence of their involvement in other programmes with incentive packages and their willingness to perform their CDD roles?

For the community members the questions may include

a. What are their perceived social and health benefits of taking Mectizan®? b. To what extent is their new interest in Mectizan® driven by the perceived social and health benefits of taking Mectizan®? c. To what extent is the interest in taking Mectizan® driven by external socio- economic factors like government paying the CDDs and the current low or no social or economic demands on the people? d. Will the people continue to want Mectizan® if they are made to play their roles fully and support the CDDs? e. If government withdraws from paying CDDs will the people take full ownership of the programme to an extent that matches their high level of demand for Mectizan® now?

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TABLE OF CONTENTS

Contents Acknowledgements ...... ii

Abbreviations/Acronyms ...... iii

Executive summary ...... vi Introduction ...... vi Summary of Findings of 2003 Evaluation ...... vi Findings of 2008 Evaluation ...... vii

TABLE OF CONTENTS ...... xiv

LIST OF FIGURES ...... xvii

1.0 INTRODUCTION ...... 1 1.1 Background to the SWII Project Evaluation in 2008 ...... 1 1.2 Re-evaluation Questions ...... 2 1.3 Evaluation Objectives ...... 3

2.0 METHODOLOGY ...... 4 2.1 Design ...... 4 2.2 Population ...... 4 2.3 Sampling ...... 4 2.4 Sources of Information ...... 5 2.5 ANALYSIS ...... 5 2.6 Summary of Findings of 2003 Evaluation ...... 6

3.0 EVALUATION FINDINGS ...... 8 3.1 Sustainability at Project/Provincial Level ...... 8 3.2 Sustainability at the District Level ...... 21 3.3 First Line Health Facility (Health Area) Level ...... 28 3.4 Sustainability at the Community Level ...... 36 3.5 Comparative Analysis of the Sustainability of the Four Levels ...... 43

4.0 CONCLUSION ...... 47 4.1 Grading the Overall Sustainability of SWII CDTI Project...... 47 4.2 Comparison of the Project Performance during 2003 and 2008 Evaluations following Implementation of the Recommendation of 2003 Evaluation Team 55

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4.3 Feedback/Planning Meetings: ...... 59 4.4 Way Forward ...... 62

APPENDIX ...... 67 I: Programme of Activities in the three day Feedback/Sustainability Plan Development ...... 67 II SWOT Analysis South West II CDTI project in the South West Province of Cameroon ...... 69 III Solutions to the Weakness and Threats in SWII CDTI ...... 88 IV Persons Interviewed at the SWII Evaluation ...... 95 V List of Documents Observed ...... 97 VI ADDRESSES FOR EVALUATION TEAM MEMBERS ...... 98 VII Minutes of the Feed back/Sustainability Planning Workshop ...... 99 Viii Speech Delivered by the Provincial Delegate ...... 105 IX Attendance List at the Feedback/Planning Workshop ...... 107

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LIST OF TABLES

Table 1 Distribution of Samples in Health Districts/Division, Health Areas and Communities

Table 2 Average Sustainability Score of the Different Groups of Indicators by Levels of CDTI Implementation in SWII CDTI Project

Table 3 Actual Contribution of Partners to SWII CDTI Implementation

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LIST OF FIGURES

Figure 1: SWII CDTI: Sustainability at Project Level

Figure 2: SWII CDTI: Sustainability at District Level

Figure 3: SWII CDTI: Sustainability at FLHF Level

Figure 4: SWII CDTI: Sustainability at Community Level

Figure 5: Average Performance of the Different Levels of SWII CDTI Pooled Groups of Indicators

Figure 6: Sustainability Score of the Groups of Indicators and Level of CDTI Implementation in SWII CDTI Project

Figure 7: Average Performance of Each Group of Indicators in the Entire Project

Figure 8: SWII CDTI Project: Performance of Group of Indicators

Figure 9: Trend in Treatment Coverage for the 2005-2007 by Level of Implementation

Figure 10: Comparative Performance on All Groups of Indicators in the Entire Project 2003 & 2008

Figure 11: Comparative Average Performance of All Levels of Implementation in the 2003 & 2008 Evaluation Periods

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LIST OF CHARTS

Flow Chart 1: Mectizan® Flow in SWII CDTI Project

Flow Chart 2: The Process of Accessing Funds for CDTI Activities in 2003

Flow Chart 3: The Process of Accessing Funds for CDTI Activities in 2008

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1.0 INTRODUCTION

1.1 Background to the SWII Project Evaluation in 2008

The Southwest II CDTI project is one of the two CDTI projects within the Southwest Province, with administrative headquarters in Buea, Cameroon. It was approved for APOC funding support in 2000, SWI having been approved earlier in 1997 to cover only nine out of the then 14 health districts endemic with onchocerciasis.

At the beginning, SWII had a population of 405,320 in five health districts. By 2007, the population of SWII was estimated at 717,969 persons with 237,874 at risk of onchocerciasis. Three new health districts have since been carved out of the earlier five to give eight health districts now. Thus, today, the SWII CDTI project covers eight health districts, namely Akwaya, Eyumojock and Mamfe in Manyu Division, Fontem in Lebialem Division and Ekondo Titi, Wabane, Bakassi and Mundemba in Ndian Division.

Most of the SWII project area is characterized by dense and luxuriant equatorial forest in Ndian, Lebialem and most of Manyu. However, savannah vegetation characterizes the Akwaya region that borders the Northwest province and Nigeria. The area has a very tough topography with many steep hills and valleys. This renders the terrain very rough and difficult to access. Fast flowing streams, which provide breeding site for the black fly, Simulium, run in most of the valleys.

Prolonged rainy season, (mid-February to mid December), is a feature of the area. The area is covered with hills and valleys and in some areas thick tropical rain forest. Rocky riverbed, interrupted by falls, is a distinguishing feature of the area. These contribute to the aerated waters, which creates conducive habitat for Simulium, the vector for Onchocerciasis, and also make the communities inaccessible.

The traditional council, chaired by a Chief, heads each village. It is this traditional council that makes decisions for the day to day activities of the village. The main occupations of the people include farming, trading and hunting.

The SWII CDTI project has an Onchocerciasis Programme Officer (OPC) as the focal person for CDTI implementation at the Provincial level. The DMOs are the coordinators of CDTI implementation at the District level while the Chief of Post oversees implementation at the Health Areas level. At the end of the third year of implementation in 2003 the project underwent the mid term evaluation for sustainability between April and May 2003, in line with the recommendations of the representatives of NOTFs and APOC management in the Abuja meeting of June 2002. The mid term evaluation revealed that the project was not making satisfactory progress towards sustainability. This was informed by the absence of more than five aspects and critical elements of the sustainability respectively in the project. It lacked community ownership, had very complicated and unreliable Mectizan supply system. Leadership roles of Government partners at all levels as well as in the community were absent. Government did not initiate planning and implementation and made no financial contribution to the implementation of the CDTI project. Specifically, the project had serious barriers to sustainability and was required to

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rethink the roles of the partners as well as appropriate and carefully targeted HSAM activities to inject the right sense of ownership of the programme at the appropriate levels (Government and communities) as well as mobilize sufficient support for the sustainability of CDTI post-APOC.

In the feedback/planning meeting that followed it was agreed that the situation where the Provincial Delegation of Health is not in ‘driving seat’ for planning and implementation of the CDTI project should be rejected and action put in place to correct the anomaly. In specific terms, all partners should recognized and respect the leading role of the government on the lines of the project proposal and the annual project agreements between WHO/APOC and Government.

Now in its 8th year of implementation, and five years after the mid term evaluation, the project is being re-evaluated for sustainability. The Evaluation Team drawn from Nigeria and Cameroon was charged with the tasks of:

• Re-valuating the sustainability potentials of SWII CDTI project to specifically identify efforts at implementing the recommendations of the mid term evaluators • Discussing the findings and conclusions of the evaluation with the Provincial, District and supporting NGDO partners as well as the NOCP • Facilitating the development of five year post-APOC sustainability plans to be prepared by the project leadership

The evaluation team visited three health districts, six health areas and twelve communities in three administrative divisions in the SWII project area to collect information from all the partners including the community members on the different sustainability indicators. The team also interacted with key actors at the Provincial and National levels as well as the NGDO. Feedback and sustainability planning meetings were health for the Provincial and District level implementers to develop five-year post APOC sustainability plans for the different levels of CDTI implementation.

1.2 Re-evaluation Questions

1. What steps have been taken to implement the recommendations of the mid term evaluation for sustainability in SWII CDTI project? 2. How sustainable is the SWII CDTI project now? 3. What are the structures now in place to sustain SWII CDTI programme as APOC pulls out it support for the implementation? 4. To what extent is the CDTI process part of the routine processes of health delivery in the District? 5. How integrated are the support activities of CDTI into the health systems? 6. How are the Mectizan® procurement and delivery mechanisms performing? 7. What is the financing mechanism put in place to ensure the availability of local and dependable source of funding of SWII CDTI project when APOC pulls out? 8. What is the state of preparedness of the Government partners at all levels to maintain, replace and ensure the availability of transport and capital equipment for the continued delivery of Mectizan® to the people for long term treatment? 9. How committed are the human resources for CDTI implementation in SWII CDTI project focus?

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10. What are the coverage results of the CDTI project in the last three years of implementation of the project? a. Are all communities identified by REMO for treatment receiving treatment? b. Is treatment coverage ≥ 65 per cent? c. What are the trends in both geographical and therapeutic coverage rates?

1.3 Evaluation Objectives

The general objectives for the re-evaluation exercise are to determine the sustainability potentials of the SWII CDTI project by its 8th year of operation and assist in developing plans for sustaining the project post-APOC

The specific objectives therefore are:

a) To assess the performance of the different groups of indicators of sustainability of CDTI projects in the SWII CDTI project b) To identify the factors that may block or help the sustainability of the project c) Discuss the outcomes of the evaluation exercise with the relevant stakeholders in the SWII CDTI project d) Develop plans for sustaining the SWII CDTI project post APOC

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2.0 METHODOLOGY

2.1 Design

The design for the study is functionally evaluative however the cross-sectional descriptive design was employed as the process for data collection. This design ensured the one-time collection of data that permitted the description of the sustainability potentials of the SWII CDTI project, having been in operation for the past 8th years with APOC funding support. In line with this and with respect to the evaluation objectives and questions that need to be answered, data were collected in order to provide the analysis required in providing answers to the research questions.

2.2 Population

The SWII CDTI project covers a total of eight health Districts with an estimated population of 717,969. The REA that supported the establishment of the SWII CDTI project put the population at risk of onchocerciasis at 237,874 in 506 hyper- and meso-endemic communities. This implies that at least one in every three persons in the project focus is at risk of onchocerciasis.

The population for the evaluation in the SWII CDTI project area, however, includes the key players in the process of ensuring long term annual treatment with Mectizan® of the people living in the onchocerciasis endemic areas. These were the members of the PDPH Team in Buea and the NOTF in Yaoundẻ; the eight district health service (DHS) teams; the Health Areas/ Health Centres staff, the project communities and their CDDs. The others were the project’s finance officer and the NGDO partners (SSI).

2.3 Sampling

A multi stage sampling techniques was adopted. This entailed the selection of health districts and health areas within the SWII CDTI project focus as well as communities for the evaluation. First three health districts were randomly selected out of the existing eight health districts in the SWII focus CDTI project and were included in the evaluation exercise. Two Health Area health centres (FLHFs) were selected by balloting from the list of health centres in each sampled health district, giving a total of six health areas (FLHFs). The simple random sampling approach was also adopted in selecting two communities from each Health Area prior to the evaluation visits. See details of the sampling in Table 1 below.

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Table 1: Distribution of Samples in Health Districts/Division, Health Areas and Communities:

S/N Health Rx (Coverage Health Area Community/Villages (Rx District Rate) Coverage Rate) (Division) 1 Fontem High (82.9%) Fotabong (80%) 1. Eselewon1 (87.3%) (Lebialem 2. Belap (68.9%) Division) Takwai (84%) 1. Takwai (81.7%) 2. Ebensuck (88.4%) 2. Ekondo Titi Medium Illor (72%) 1. Dibonda (49.1%) (Ndiam (79.6%) 2. Illor (81.6%) Division) Ekondo Titi (87%) 1. Lobe Town (77.0%) 2. Ekondo Nene (82.9%) 3. Eyumojock Low (65.5%) Afap (59.8%) 1. Mbakang (65.7%) (Manyu 2. Afap (52.3%) Division) Kembong (65.4%) 1. Nfuni (70.4%) 2. Ossing (69.6%) or Mamfe Bachuo Akagbe (82.2%) 1. Bachuo Ntai (81.5%) (Manyu 2. Mbinjang (89.9%) Division) Tali (79.0%) 1. Tinto (72.2%) 2. Ebeagwa (78.5%)

2.4 Sources of Information

Information were collected from interviews, verbal reports and documents. Various categories of people were interviewed in the Province. These included the Provincial Delegate of Public Health (PDPH), Chief of Unit for Supervision, Monitoring and Evaluation, Onchocerciasis Programme Coordinator (OPC), Chief of Service (General Affairs including Transport and Human Resources) and Essential Drug Manager as well as the Country Representative of the supporting NGDOs (SSI) and her team. At the District level, the District Medical Officers (DMO), District Administrative and Finance Officer and Chief of Bureau (Health) as well as the Senior District Officer (SDO/DO) were interviewed. Other persons interviewed were at the Health Area levels (Chief of Post – FLHF) and the communities (community leaders, CDDs and community members).

Information was recorded on the evaluation instruments and discussed extensively before the Evaluation Team undertook the grading of the level of performance on the indicator by level of CDTI implementation.

2.5 ANALYSIS

Based on the information collected, each indicator was graded on a scale of 0-4 (worst to best), in terms of its contribution to sustainability. The average 'sustainability score' for each group of

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indicators was calculated, for each level, and a graph was plotted. Summary statistics for the scores were calculated for each level, and for each group of indicators, and tables and graphics of these results as well as illustrative quotes from the field were presented at feedback workshop. The quality of the overall project was also assessed in using the different aspects and critical elements of sustainability present in the project.

The five critical elements and the seven aspects of sustainability in the project were qualitatively discussed and results agreed to by the team in open discussion. The project was graded using these aspects and elements in accord with APOC guidelines. The evaluators discussed qualitative description of problems, and deliberated on likely suggestions for solving the problems identified.

Thus judgment about the sustainability potentials of the project was based on the quantitative assessment of the average sustainability scores of the groups of indicators as well as the qualitative assessment of the critical elements and aspects of sustainability of the project.

Recommendations were generated in the format recommended by APOC.

2.6 Summary of Findings of 2003 Evaluation

The 2003 evaluation concluded that the SWII CDTI project was not making satisfactory progress towards sustainability. Quantitatively, the project earned 2.17 points, which was far below the 2.5 points benchmark for satisfactory performance. It was scored low on almost every group of indicators, with the exception of planning, Training/HSAM and human resources 2.88, 2.73 and 2.68 points respectively. On finance, transport, integration and worst of all coverage, the project was scored 1.03, 1.97, 1.00 and 1.70 points respectively. In terms of the levels of implementation the project had the worst performance at the Provincial/project level (1.92 points). Leadership, an indication of ownership of the project, was non existent here.

There was an over bearing attitude in the NGDO and the project was seen as SSI project. SSI directed the implementation of the project generally from Yaoundẻ, the administrative seat of SSI in Cameroon. Leadership and political commitments were weak. The best level was the health area or FLHF with 2.64 points. The other levels, community and District scored 2.00 and 2.11 points respectively. The communities were not empowered to decide on the mode, period and number of CDDs to select. SSI and the health staff selected CDDs in many cases.

The project was also evaluated on its performance on the aspects and critical elements of CDTI implementation respectively. The evaluation team concluded that the project had serious barriers to sustainability and would require rethinking of the roles of partners as well as appropriate and carefully targeted HSAM to inject the right sense of ownership of the programme at the Project and community levels as well as mobilize sufficient support for the sustainability of CDTI post-APOC.

The evaluation team found three deficiencies that would seriously block sustainability because their virtual absence in the project. These included community ownership, uncomplicated and reliable Mectizan® supply system and leadership role of government partners at all levels and

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community. The communities were the least involved in the implementation of CDTI. This was considered very critical for sustainability of the project.

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3.0 EVALUATION FINDINGS

3.1 Sustainability at Project/Provincial Level

Fig. 1: SWII CDTI: Sustainability at Project Level

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Groups of Indicators

Planning (Highly; 3.0)

There is an overall written year plan of the health service at the project level, including the provincial level. This plan contained onchocerciasis, which is also listed as a priority problem in the area of focus. There is also a more detailed plan, which contains all key elements of CDTI. The different partners, government and NGDO (SSI), participated in the development of the plans. The participation of the partners was documented in minutes of the meetings where the plans were developed. Attesting to this, the SSI country representative said,

…after appraisal meetings the Districts plan with their health areas based on the timing requested by the communities. This may alter because of late funding or late arrival of Mectizan®, as we experienced this year. Mectizan® could be late because of the requisition process. Some National activities could also affect distribution. We (SSI) are actively involved developing the action plans.

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In the office of the Provincial Delegate of Public Health, there is a Provincial Comprehensive Health Plan. The plan made adequate provisions for the control of onchocerciasis. Furthermore, the OPC has developed a three year (2007-2009) sustainability plan. According to the OPC,

…our Minister directed that we develop a three year sustainability plan, after the meeting APOC held in Douala for the future of APOC. I personally developed it and showed it to my superiors, here in the delegation before it was forwarded to the Ministry. We are still waiting for his response.

There was however no evidence that the sustainability plans were shown to other partners for their input. Obviously the NGDO partner was not aware of the new sustainability plan. According to the SSI country representative, “…beyond the 2003 sustainability plan, which was developed after the evaluation, we have not done any other”.

Furthermore, the detailed plan did not differ for the three years (2005-2007) because according to the Onchocerciasis Programme Coordinator (OPC),

there has been an introduction of Eye Case programme which is now implemented along with CDTI. There is also the problem of the low skills among the workers at the lower levels and the recruitment of new nurses. All of these make it necessary to train every year.

The delegation did not also seem to be clear on its roles and responsibilities as they expected the NGDO to support the project finance officer. The NGDO partner actually supported the project finance officer throughout the period he served the project int hat capacity.

Integration (Fully; 4.0)

There is ample evidence of integration of activities in the project. There is a written work plan, which shows how activities are implemented in an integrated manner. For instance, staff combined tasks during routine health monitoring/supervision. Staff combines CDTI activities with those of other programmes, where this it is possible.

The integration of activities and programmes is also recognized by the operators at this level as a major ingredient for the success of health services in the area. The supervision and monitoring of activities are coordinated in the office of the Provincial Chief of Unit for Supervision, Monitoring and Evaluation (PCSME) and she organizes regular evaluation of the project performance along with other programmes in the Delegation.

Leadership (Highly; 3.0)

The leaders (the Delegate, OPC, chief of unit for supervision, monitoring and evaluation, etc) are well aware of the progress, successes and problems of the project. The Delegate, for instance, identified CDD motivation as the major problem in the project. He went on to highlight the problems associated with payment of CDDs, as volunteered by the Minister in response to the low coverage reported years earlier. According to him,

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…if you do not pay the CDDs everything will go down. But we are trying now to push them into the dialogue structure (village health committees), where there is money. We want the communities to set up the committees and the CDDs will be catered for in the process.

The OPC noted that the problem as CDD motivation and low coverage reported in some communities. According to him,

…one big problem is the payment of the CDDs, which the Minister promised during the stakeholders’ meeting in Kribi. This has been irregular since 2006. Another concern is the low treatment coverage in some health areas. Generally, coverage has been on the increase. Two years ago when we realized that coverage at the provincial level is increasing we decided to focus on the communities. In 2005 we had 137, in 2006 we had 112 and in 2007 we had 84 communities with coverage <65%. Our concern is to get all the 506 communities score 65%+.

The Chief of Unit (Supervision, Monitoring and Evaluation) however argued that the seemingly low coverage figures are due to computational problems. In her words,

…we have areas where there are population figures but when you get there you do not find people. We have denominator problem. This is not only for CDTI. It affects other programmes as well. One such place is in the Mundemba area.

To solve the problem of CDD incentive she also corroborated the Delegate. According to her, “we planned to train the dialogue structures with the special health fund. This way we hope to increase community ownership”.

In a nutshell, the leaders have assumed leadership roles for the implementation of the project following the reports and recommendations of the 2003 evaluation. According to the Provincial Chief of Unit for Supervision, Monitoring and Evaluation,

…when the project started we thought it was SSI project. But thank God after the mid term evaluation the team came up with a lot of findings and recommendations which we had to implement. There were issues of leadership and APOC finance officer. When we realized that it was ours we had to sit up. Since then we are trying to take up the leadership. We no longer wait for SSI. We have the budget and we plan our activities….

The leadership is up to date with its reports and targeted activities. The leadership delegates responsibilities appropriately to colleagues at this and lower levels. The leadership has a sound and collegial working relationship with junior colleagues, and keeps them fully informed. NOTF meets regularly and its members are fully aware of current issues in the CDTI programme.

However the Provincial Chief of Service for General Affairs lacked sufficient knowledge of the workings of the programme at this level. In his words,

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…I am not involved in the budgeting and financial management of CDTI probably because the project has a finance officer. I know only of government input for payment of CDDs. I have no clear idea of the cost of the project.

The Delegate blamed this on the entire set up. According to him, this is not peculiar to CDTI.

…. If we take another project like EPI, Roll Back Malaria, TB, the question concerning account might be the same. The problem of job description might be the same. The problem of implication of the Delegation and appropriation of all these vertical projects might be the same.

He thanked the evaluators for the revealing finding and argued further that,

…vertical implementation of project activities and of course fund management is a fundamental problem in health care delivery system in Cameroon, which the government is now trying to address with the sector wide approach (SWAP).

The SSI partner of the project summarized all of these facts pointing to the fact that the Delegation has assumed leadership of the project. According to the SSI representative,

…the project has reached a mature stage where the Province and Districts carry out project activities. Before we used to push but now we get request from the Province. I have the feeling that Districts need some pushing from the Province. They have not reached the stage where District is pushing…. They are still strongly dependent on external funding. That may explain why they are not pushing enough…. Reporting has improved.

On the working relationship in the project, the SSI representative said, “in this project there is a good working relationship”.

Monitoring and Supervision (Fully; 4.0)

Relevant records were readily available to show treatment summaries and inventory of equipment, among others. The records are of good quality, the contents clear, detail and convincing.

Supervision is based on objective needs. The OPC supervises the DMOs. Staff members at this level go beyond the level immediately below, even to the community to resolve problem but that is only when the DMOs request support from the Delegation. According to the OPC,

…we only supervise the District level. Unless when there is a serious need then we can even get to the communities.

Monitoring/supervision is being planned to make for efficient use of resources. Generally, available information revealed that resources for supervision are efficiently managed as there exists a supervisory plan for the health system, which makes for shared use of resources.

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Supervisory visits are thorough. Checklist, which also provides the basis for approval of planned field visits by the authorities, exists at this level. Staff members plan for one or two routine supervisory visits for onchocerciasis per year, depending however on availability of funds and other conditions. According to the OPC,

…supervision depends on availability of funds and where there are problems. Resources are efficiently used for supervision. In 2007 there were two visits; 2006 one visit.

Problems and successes identified in the process of monitoring and supervision are addressed in a very deliberate and systematic manner. As soon as problems are identified the appropriate officer deals with them. Such problems are passed to the DMOs but on request of the DMOs the Delegation assists in handling the problems. According to the OPC,

…when we noticed low coverage due to the attitude of the people, we may join the DMOs on request to health educate the community leaders showing them their performance in comparison with the performance of other communities close by.

Successes are recognized and feed back given in a systematic way. Furthermore it was observed that the reporting of CDTI activities is within the Government system.

Mectizan® Procurement and Distribution (Highly; 3.0)

Mectizan® supply is controlled within the government system. The Provincial Manager of Drug Programme handled the collection and distribution of Mectizan®, along with other drugs for the Delegation of Public Health. According to the Manager of Southwest Province Special Fund for Health, who is in charge of the drugs in the Delegation,

…I order the drug annually based on the previous year’s consumption, store in the central store with other drugs and distribute to the DMOs…. This has been the case following the results and recommendations of the 2003 evaluation.

The system is effective, uncomplicated and efficient. More importantly, it is dependable and sustainable.

There was sufficient Mectizan® for the needs of the project area, though this year (2008) Mectizan® came late due to the logistic problems associated with drug ordering at the National level. Explaining the late supply of Mectizan®, the OPC said,

…previously projects made their requisition straight to MDP. Then Mectizan® for any year came early. But since the 2006, it was decided that Mectizan® should be done centrally. Unfortunately, it was observed that some people did not know how to make the requisition for what they needed. The NOTF decided to hold a training, where we all sat together to make the requisition for the country. This was in October 2007 and it meant that the request was sent late and the drug arrived late.

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On the problems associated with Mectizan® ordering and procurement, the SSI programme officer said the problem they had last year that led to the late arrival of Mectizan® in 2008 was due to the new process in ordering Mectizan®. According to him,

…in the past each project ordered the Mectizan® it needed straight from MDP. Since 2006 it changed to one order for all the projects in the country. Now, some projects do not complete distribution until late October. Worse still, the change in MDP and the exit of Mary Alleman affected the supply of Mectizan® to the country.

The District Health Service collect the Mectizan® requirement for their various Health Districts from the Provincial Pharmacy using definite Mectizan® order forms. The requisitions of the different Health Districts were located with the Provincial Drug manager. It is on these requisitions that the number of tablets needed by the Health Districts is compiled and forwarded to the appropriate quarters.

Training & HSAM (Highly; 3.3)

Training is planned and undertaken in an efficient manner. No training has held for this year. According to the OPC, “we only supervise the training of the Health Areas staff. The DMOs have been sufficiently trained”

Health education, Sensitization, Advocacy and Mobilization (HSAM) was properly planned and carried out based on perceived need. Every opportunity for addressing any audience perceived important for the implementation of CDTI was seized and used. For instance, the Provincial Delegate for Public Health said he uses the opportunity of the SW special fund for health to sensitize people about all health programmes including onchocerciasis control. According to him, “this is the highest dialogue structure. The Governor chairs the annual meeting while I, the Delegate, chair the quarterly meetings”. He also indicated that he uses the SW chief’s conference to advocate for eye care and CDTI.

All the same, there was no evidence of increased government financial support for CDTI implementation in response to these HSAM activities. No HSAM activities are undertaken at the Provincial level. The OPC noted that the Governor is not aware. According to him,

…you must have noticed, from our meeting with the Governor, today, that he does not know much about CDTI. We do not do HSAM at this level because the Radio here does not get to our area of coverage. So it is at the District level we do HSAM.

The evaluation team had to remind the OPC that HSAM is not only for those benefiting directly from the distribution of Mectizan® but also for the stakeholders in the health of the people. The Governor needs to be sensitized on the disease and CDTI. More importantly, advocacy should be conducted on the Governor’s office to get the political and administrative backing of the Governor’s office and if possible financial support for the programme.

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Finance Resources (Slightly; 1.3)

The costs for each onchocerciasis control activity were clearly spelt out in a budget and there is evidence of cost reduction. The OPC had clear estimates of the funds that will be available for onchocerciasis control in the coming year as well as the expected sources and made budgets for CDTI implementation to fall within this expected and estimated income. However, the Delegate, the chief accounting officer for the Delegation, is not clear about what is available for the implementation of the CDTI programme. According to him,

…I do not know whether the APOC funds are still there. I know that sometimes papers come and they say APOC is paying or SSI is paying. I simply sign. The project accountant has gone without telling me. I decided I will not go into the office of the APOC finance officer until SSI has come to take inventory. SSI was paying him.

The finance officer (PCSGA) of the delegation does not know the budget for the programme and the contribution of APOC and SSI. According to him,

…I am not told anything. All these projects come with their project accountants and they do not tell me anything. I can only tell you what Government puts into the projects but not what the donors contribute.

There was evidence of approval of expenditure, and funds for expenditures were allocated according to the approved plan of action. The Delegate approved both the proposed expenditure and funds for the implementation of CDTI in line with the work plan drawn by the Onchocerciasis control team. However, all the operations for the control of onchocerciasis at this level were funded largely by APOC and SSI. The OPC noted that, “Government provides nothing except in the maintenance of vehicles and other capital equipment. Most of the money from Government is spent on paying the CDDs”.

The financial officer of NOTF however noted that the Government funds the project in many respects. According to him,

There are two types of funding – direct and indirect. Direct funding concerns the motivation of CDDs. Indirect funding, which is the money sent to the PDPH, that is in the budget for the Delegation you will not find a line on CDTI. But all the money sent here can be used for CDTI. In addition, usually at the NOTF we send some money to the OPC for supervision.

He went on to indicate that in 2004 and 2006 the MoH disbursed US$28,268.00 for the payment of CDDs. Furthermore, the NOTF supported supervision of CDTI in the project with US$541, US$601, US$361 and US$180 in 2004, 2005, 2006 and 2007 respective. “We also sent some HSAM materials, which we produced with the HIPC fund”.

When asked why the funding support from the NOTF is decreasing, the NOTF finance officer said, “to meet HIPC conditions for further support we needed to show evidence of cost containment and reduction in expenditure”. He proceeded to justify the decreasing funding on the state of the nation’s finance. According to him,

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…the decreasing funding is due to the financial situation of the country. The MoH makes the budget but the Ministry of Finance decides what to pay. They even wanted to reduce the budget further but the Minister of Public Health will always plead that the CDTI activity is crucial and further reduction could jeopardize the programme.

Project management is aware of shortfall but has no specific and realistic plan to bridge the shortfall. It relies on SSI to make up the shortfall. Unfortunately, there is also a shortfall between what is expected from SSI and what SSI is ready to give. According to the Delegate, “SSI has not been able to completely fill the space created by the fall in APOC funding. The only other way is to integrate activities”. He argued that this is because of the poor funding situation of the delegation. However, the Chief of Unit for Supervision, Monitoring and Evaluation noted that, “APOC and SSI funds are made available and arrangements are made to ensure that CDTI work is not blocked anytime because of unavailability of funds”.

SSI finance officer said,

…the project team has managed to cope with shortfall by cutting cost. For instance, they have now learnt to train without per diem. We also hope to build their capacity to mobilize resources locally.

The SSI country representative reaffirmed this fact and assured that, “SSI will fund the training on resource mobilization…. With the integration of Eye Care, there are also funds coming from Eye Care”.

In thinking of the future, the Delegate emphasized that,

…it is hoped that with the planned sector wide approach (SWAP) funds in the delegation will be used in an integrated manner and this way it will be possible for the Delegation to source funds from the common health basket and support all programmes within the delegation.

Funds disbursed for onchocerciasis control from the budget at this level are efficiently managed. There is also a well established control system used in disbursement of funds. The chief accounting officer in the Delegation is however unaware of residual amounts under different budget headings.

As the financial officer of the NOTF I used to control their financial report. I have also been here to train the former project finance officer [NOTF Finance Officer].

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Transport and other Material Resources (Moderately; 2.3)

Transport and materials are available and functional for CDTI activities. The project has one 4WD Hilux double cabin vehicle supplied by APOC. The project has 21 motorcycles, (20 from APOC and one from SSI). APOC also supplied a Desk Top Computer and accessories, which broke down long ago. SSI replaced this to make sure work is not stopped. Other capital equipment supplied by APOC include photocopier and fax machine. Other supplies include posters and leaflets as well as a training manual from APOC.

As can be noticed, all the supplies necessary for the implementation of CDTI in the area are from non-government sources. All the same, there are transport and other material resources in the Provincial Delegation for Public Health at the disposal of the Onchocerciasis control programme.

The Delegation maintains the vehicle and other equipment. All the same, according to the Delegate, the Province has two problems namely vehicles and personnel. The personnel problem is really acute. The PCSGA indicated that they carry out routine maintenance of vehicles and other equipment. In his words,

…we have recruited an engineer for preventive maintenance of computers, photocopiers and the internet system.

Capital equipment and supplies may need replacement considering the work still to be done in the coming 5-10 years. This then requires the government to rethink its place in the supply of capital equipment and office requirement for the successful implementation of CDTI. The Delegate demonstrated his helplessness when he said,

…there is no plan for replacement. Replacement from Government standpoint? …no hope…. Government just sends vehicles when they feel like doing so. You cannot predict Government. This year they approved some vehicles for my Districts but now there is a directive withdrawing all the vehicles due to problems they have with the budget at the National level…. We only rely on WHO.

The Country Representative of SSI however assured that, “SSI will continue to support the maintenance of vehicle and other capital equipment”.

Transport at this level is used to undertake support activities at the next level. Transport is properly controlled with trip authorization, and log books as is the general practice in the delegation. According to the PCSGA, “we issue travelling authorization to each beneficiary but no copy is kept at the delegation”.

The team however observed that the travelling authorization is for the security clearance of the personnel and not so much a permission to use the vehicle.

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Human Resources (Highly; 3.5)

Staff members at this level are very stable and committed to their CDTI implementation work. The Onchocerciasis control team members have remained in one place for an average of five years. The Project Coordinator (OPC) has been in the project area for eight years.

There is also a high level of commitment among the staff. According to the Delegate,

…the OPC is very dependable and highly committed to his CDTI work. I can even give him 100%. Even the general demoralization that came with the withdrawal of APOC financial support to personnel did not stop him from doing his work. He carried on until the Eye Care programme was introduced.

Other officials at this level corroborated this information. According to the Provincial Chief of Unit for Supervision, Monitoring and Evaluation, “…they are doing their work. It is one of the priority projects of the whole Cameroon”.

The SSI country representative, SSI programme manager and SSI finance officer were all agreed on the level of commitment to the CDTI work by the Southwest II CDTI implementers. In the words of the country representative,

…the provincial staff is committed. We do not expect all of them to be knowledgeable at the same level. But I will say they are making good efforts to ensure the work succeeds. The bottom line is that if these guys are not committed this will not be happening…. The work load and pressure from the DMOs and communities are enormous. You will find they are very committed.

However, there are indications that the OPC will soon proceed on retirement. The leaders at this level however argued that this is not a threat to the implementation of CDTI in the project area. According to the Provincial Chief of Unit, Supervision, Monitoring and Evaluation,

…thank God we have two OPCs. We shall either get somebody to understudy him before he leaves finally or the other OPC will oversee the project while we train another to take over. Recently Government recruited new staff. I have many who have reported to me I am still considering where to post them…. So that is not a problem at all.

Beyond the OPC, the team has been the same except for the Delegate, the Pharmacist and Chief of Service General Affaire who joined later.

All the same, the project accountant was not from within the government system. Following the recommendations of the 2003 evaluation, the project accountant hired and paid by SSI was merely relocated to Buea. He was however not answerable to the leadership of the Delegation since the Delegation was not paying his salaries.

Explaining this anomaly, the SSI country representative said,

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…the reason why we could not use a government person as project finance officer is because of the nature of the requirements…. Government employees will not respond as fast as would be desired

Coverage (Fully; 4.0)

Geographical coverage has been 100% in the last three years (2005-2007). All the areas identified by REMO for mass treatment are under treatment. Treatment coverage ranged from 72.9% in year 2005 to 75.1% and 76.2% in 2006 and 2007 respectively. This shows a steady increase in treatment. People are beginning to show more interest in the drug and communities are beginning to demand for the drug.

In response to the observation made by the evaluators on the poor coverage situation in Eyumujock due to the problem of loa loa in Ogurah, the SSI country faulted the DMO. According to her,

…it means the Eyumujock man is not doing his work. What happened in Ogurah is that laboratory technicians screened everybody in that area for loa loa. The list of people who could take Mectizan® was given to the DMO. The DMO is not pushing. He needs to have someone who is pushing. In short we cannot do CDTI there else the project will break down again.

Differing slightly, the SSI finance officer said,

…we may have to look at ways of intensifying HSAM in that area. We cannot blame them because they are scared of side effect…. I am from that area and I know of a woman who said she would rather die than take a drug that will put her through so much pain and misery.

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Recommendations for the Project Level

Recommendation Implementation Planning Priority: HIGH ¾ There should a written plan of action for Indicators of success: CDTI based on need a) Existence of action plan with ¾ All partners should be actively involved in targeted activities endorsed by all developing plans for sustainability showing partners reliability of funding sources b) Minutes of planning meeting c) Existence of sustainability plans with reliable funding sources Who to take action: PDPH Deadline for completion: December 2008 Leadership Priority: HIGH ¾ Sensitize the leadership at this level on Indicators of success: their roles and responsibility in CDTI a) Minutes of sensitization workshop b) All members of the leadership demonstrating good understanding of the programme and their roles Who to take action: PDPH Deadline for completion: End of next distribution Mectizan® Priority: HIGH ¾ Ensure timely supply of Mectizan® in future Indicators of success: a) Report of requisition of Mectizan® Who to take action: Manager, Provincial Drug Programme Deadline for completion: Before of next distribution Training & HSAM Indicators of success: ¾ Conduct Sensitization and Advocacy visits b) Minutes of sensitization workshop to the Governor and other Political Leaders c) All members of the leadership in the Province demonstrating good understanding of the programme and their roles Who to take action: PDPH Deadline for completion: End of next distributio Financial Resources Priority: VERY HIGH

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¾ Government should assume a major role in Indicators of success: funding CDTI activities by increasing its a) Increased amount budgeted and budgetary allocations and releases for CDTI released for CDTI activities implementation b) Evidence of sensitization of the ¾ Efforts should be made to get Government government on need to channel channel the funds used for payment of funds to supporting CDTI at this CDDs into supporting the CDTI level implementation process at this level c) Evidence of Government support (increased funding) for the implementation process at this level Who to take action: PDPH and NOTF Deadline for completion: End of next distribution period Transport and Material Resources Priority: VERY HIGH ¾ Government should provide reliable plan for Indicators of success: replacing transport and other capital a) Evidence of planning for equipment for the implementation of CDTI replacement of vehicle and at the lower levels equipment b) Signed MoU from the highest authorities of organizations promising to replace vehicles and capital equipment c) Transport made available for CDTI at lower levels Who to take action: PDPH and NOTF Deadline for completion: End of the next distribution period

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3.2 Sustainability at the District Level

Fig. 2: SWII CDTI: Sustainability at District Level

4 4 4 3.5 3.5 33 3 3 ) 3 /4 ( 2.3 ht2.5 ig e 2 1.5 W 1.3 e1.5 ag r 1 ve A 0.5 0

Groups of Indicators

Planning (Highly; 3.0)

There is a general plan of action for all health activities at this level and CDTI activities were included in the District Health plans of two of the three health districts covered in this evaluation. The written work plans had all the elements of CDTI, and were drawn in a participatory manner involving all stakeholders.

However the plans were routine. Activities were not targeted and unjustified. No reason was given for the routine planning of activities. The officer in charge simply said that, “what we do is to produce plan for one year and then replicate it for other years”. Further more, the plan was not integrated in one of the health districts visited. In this district each programme planned its activities vertically.

Integration of Support Activities (Highly; 3.0)

The various support activities are planned and carried out in an integrated manner in two of the health districts visited. Staff members combine activities of CDTI and sometimes, different programme activities in one trip. CDTI is also integrated with the Eye care programme.

CDTI support activities were however not integrated in one of the districts. Every programme carried out its own activities. The newness of the team was given as reason for this parallel

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implementation of activities. According to the DMO, “the team has not mastered their responsibilities because it has just been formed”. The district was only recently carved out of the Mamfe Health District. The team which was subsequently put together for the implementation of health activities is not yet acquainted with the details and activities in CDTI programme.

Leadership (Fully; 4.0)

The District Health Teams takes full responsibilities for CDTI activities in all the health districts visited. The management team at this level initiates activities. The DMOs are aware of the problems of the project. According to one of the DMOs interviewed,

…the project is trying in spite of some difficulties. The major difficulty is the CDD problem. They have not been paid for 2006/07. That is the only problem…. This year we had the training of the dialogue structures and we told them about CDTI. They assured me that the programme will not die, even where the government fails to pay the CDDs. Even for CSM, we give them example with their farms. If you spray your farm you need to come back to see if you covered all the plants, else the pest will destroy the plants in areas not sprayed. So we encourage them to do community self monitoring of the distribution.

The chief of Bureau for Health in Fontem noted that,

…initially there were refusals. But the refusals have reduced. Many people refused because of hearsay. But with sensitization they have started demanding for it themselves. Now, Mectizan® tablets are in the HAs but not yet distributed because of lack of money for training…. Initially, some CDDs accepted the job because they thought it is an opportunity to make money. When they realized that it is voluntary they dropped…. The problem now is the payment of CDDs. We are trying to make the communities understand that the programme is theirs…. We evaluate the programme to identify problems. At the beginning there were refusals. Now, if there is delay the people come to ask for the drug.

Monitoring and Supervision (Highly; 3.0)

There is routine supervision at this level, using a checklist. Sometimes there is spot check in communities. There is also regular supervision of all health programmes in the District, which covers the onchocerciasis control programme. However supervision is not targeted.

Reporting is within the government system and resources of the District Health Service are used for transmitting reports. According to the DMO in one of the health districts, “we have an agency that takes reports to the Delegation. The District Health Service pays”.

As soon as problems are identified the staff at this level tries to solve it. For instance, when the CDDs refused to distribute Mectizan® because of non payment of their allowances in 2006/07

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the team went out to the dialogue structure to suggest ways the communities could motivate CDDs. Unfortunately, this got to the attention of the Permanent Secretary who was obviously displeased. According to the DMO,

…the problems we can solve we solve. Those beyond our capability we invite the provincial office to help. In one year the community decided to contribute money irrespective of the Minister’s directive. This was not acceptable to the Permanent Secretary.

However the District team does not empower the FLHF staff to handle the problem in some of the Health Areas. They moved into the communities to resolve problems without any clear justification for doing so.

Mectizan® Supply and Distribution (Highly; 3.0)

The District Health Service used Mectizan® forms for ordering Mectizan® from the Provincial Drug Programme. Requests for drugs were based on the FLHF and community data. Mectizan® was available for the last distribution and sufficient for two of the District. In one of the Districts, the team complained of shortage. The District did not receive all that was requested from the provincial level.

The system for the collection of Mectizan® is different from the system used for other drugs. The Essential Drug Programme supplied other drugs quarterly to the Health Districts but the DMOs arrange for the collection of Mectizan® from the Delegation. According to one of the DMOs,

…it usually does not arrive at the same time as other drugs do. Now we are distributing in March/April but the drug programme came in February and will come again in May.

When asked why the drug programme could not supply Mectizan® in February, the DMO said, “I am not sure Mectizan® was in the country them”.

Training and HSAM (Moderately; 2.3)

District Health Teams only train FLHF staff, and is done routinely for 2-3 days every year with no objective or targeted need for the training. Training is not integrated. According to the DMO of Fontem Health District, “we do it every year to refresh old nurses and put the new nurses through. This is necessary especially now that we are integrating eye care with CDTI”.

Resources for training are efficiently used. There is also in-service training for staff at this level.

Staff is planning and carrying out HSAM in an efficient manner. According to the DMO in one of the Health Districts visited, “we do advocacy at the level of the Senior District Officer (SDO)”. The result of the advocacy is that the SDO’s office is aware of the programme. According to the 1st Assistant to the SDO in Fontem,

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…I am aware of the programme. Just that for the past two years the government has not paid the CDDs as it promised. And the Minister has stopped the collection of money from the community members…. We are however working to make the CDDs continue with the distribution….

In one of the Health Districts visited, however, it was observed that HSAM activities are planned but inadequately executed. Insufficient advocacy is done towards traditional leaders, as they reported ignorance of the workings of CDTI programmed in their domain.

Financial Resources (Slightly; 1.3)

Costs for each CDTI activity are clearly spelt out in a budget. There is evidence of cost reduction as the years go by with increased integration of activities in the health system. Funds released are however mainly from APOC and SSI. Funds from government sources are mainly for the payment of CDDs. In one of the Districts visited it was reported that funds are usually inadequate and late in coming. According to the DMO in Ekondo Titi,

…nothing is done about shortfalls. The Health Service is not able to mobilize the resources it needs as well as its commitment to ownership

Funds are efficiently managed. All the same the question of efficiency and accountability does not arise as the funds are forever insufficient. According to the DMO for Eyumojuck Health District,

…the money received is not in conformity with the money required by the project. So we just manage it to produce the result. The essential thing is to produce the result.

Transport and Other Material Resources (Slightly; 1.5)

Government provided two motor vehicles and two bicycles. APOC provided eleven motorcycles, most of which are not functional now. SSI provided seven other motor cycles. One of the Districts visited has no transport at all. Where it is available, transport is used in an integrated manner. These motorcycles are however ran and maintained by the individual officers using them. There are also computer and training manuals in the District Health Services visited.

The District Health Service maintains the vehicles, though only when the vehicles break down. There is no plan for preventive maintenance or replacement. In Ekondo Titi the DMO said,

…the Government has the least ability to maintain the vehicle or pay for maintenance, repairs or replacement of tyres. When vehicles break down, members of staff, at this level, work by trekking long distances. Those using the motor cycles maintain them.

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Human Resources (Highly; 3.5)

Some members of the staff of the Health Districts visited have been in one post since 1995. There is in-service training. Staff members express satisfaction with their present responsibilities. According to the DMO in Fontem,

…we are happy doing the job in spite of the difficult terrain. When people are happy taking Mectizan® you are happy that you are helping them to get the drug and then you are happy too.

The Chief of Bureau Health in Fontem said,

…I am happy. First of all I must talk about the achievement. Before the introduction of Mectizan®, people were taking Notezin. Now people report of improvement in their eye sight and deworming. It is also free. When you go for training your expenses are paid. More importantly, it is integrated with other programmes. So you cannot separate them. The programme has assisted us in doing other things. For example they provided motor bikes which we use for other activities.

In Eyumojuck the staff is committed but not satisfied. According to the DMO, “the programme started with much money and the money is gradually going out. The work load is too much”

In Ekondo Titi the staff complained of the work load. According to him, “the work load is much because all programmes need so much detail”.

Coverage (Fully, 4.0)

Geographical coverage has remained at 100 per cent since 2005 in the SWII CDTI project. However, only 3 of the 15 villages that should be taking Mectizan® in one health areas (Ogura) in Eyumojuck Health District is currently receiving Mectizan® because of the high prevalence of loa loa in Ogura. They do not have any health facility to take care of the severe side effect in Ogura.

Therapeutic coverage is also high >65% in the Health Districts visited. The range for the 2005 round was 71.0% - 76.4% with an average of 73.7% (73.7±3.81 SD). The range for the following year, 2006 was 68.0% - 81.4%, with an average of 75.8% (75.8± 7.0 SD). In 2007 this rose further to 65.0%-82.9% with an average of 76.0% (76±9.6 SD).

There is a general desire among the people to take Mectizan®. According to the DMO in Fontem,

…anytime we delay in giving them the drug they start coming to ask what is happening. Gone are the days when the people refused the drug out of fear. All that fear is gone now and the people are increasingly demanding the drug. Refusals are very few and isolated.

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Recommendation for the District Level: District Recommendations Implementation Planning Priority: HIGH ¾ Planning should be targeted and Indicators of Success: integrated in all the District Health a. Minutes of meeting of planning systems b. Plan documents Who to take action: DMO Deadline for completion: End of next distribution period Integration Priority: HIGH ¾ Implementation of support CDTI Indicators of Success: activities should be integrated. a. Minutes of meeting of planning ¾ CDTI should be integrated into the b. Evidence of integrated DHS in all the Health Districts implementation of activities c. Existence and evidence of use of supervisory checklist for all health programmes within a Health District Who to take action: DMO Deadline for completion: End of next distribution period Monitoring & Supervision Priority: HIGH ¾ Monitoring and supervision should Indicators of Success: target on weak areas a. Reports of monitoring exercise

Who to take action: DMO Deadline for completion: End of next distribution period Mectizan® Supply and Distribution Priority: MEDIUM ¾ District should be given sufficient Indicators of Success: Mectizan® every year a) Report on supply of Mectizan® ¾ Effort should be made towards the integrated delivery of Mectizan® by Who to take action: the drug programme along with DMO other drugs in the Health system to avoid DMOs vertically collecting Mectizan® Deadline for completion: End of next distribution in 2008 Training & HSAM Priority: MEDIUM

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¾ Training should target need Indicators of Success: ¾ HSAM should target traditional a) List of training needs of FLHF staff opinion leaders and the elite of the b) Report of training communities to mobilize resources c) Report of HSAM for CDTI implementation d) Evidence of effectiveness of HSAM or support from community leaders e) Who to take action: DMO Deadline for completion: End of next distribution period in 2008 Financial Resources Priority: HIGH ¾ Develop plans to target only the Indicators of Success: essentials for CDTI implementation a) Report on activities for 2008 ¾ Funding of CDTI, from DHS should b) Vouchers of government fund be increased releases for CDTI implementation Who to take action: DMO Deadline for completion: End of next distribution period in 2008 Transport & Other Material Resources Priority: HIGH ¾ DHS should fund the maintenance Indicators of Success: and running of all vehicles and a) Existence of logbook equipment within the District b) Vouchers of DHS fund releases for Health System running transport and maintaining ¾ Introduce the use of logbook for equipment the control of motorcycles, Who to take action: especially motor cycles DMO ¾ All vehicles should be parked in a Deadline for completion: pool for more control End of next distribution period in 2008 Coverage Priority: HIGH ¾ Increase HSAM in communities with Indicators of Success: low compliance with Mectizan® a) Evidence of HSAM in low coverage treatment areas ¾ Develop plan for screen the b) Existence of plan for addressing the communities for Loa loa in Ogura problem in Ogura HA Health Area c) Reports on the development of ¾ Provide facilities and skills for skills in management of side effects managing severe side effects where d) Report of management of side there is co-endemicity of effects onchocerciasis and loa loa e) Coverage increased in Eyumojuck Who to take action: DMO and OPC Deadline for completion: End of next distribution period in 2005

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3.3 First Line Health Facility (Health Area) Level

Fig. 3: SWII CDTI: Sustainability at FLHF Level 44 4

3.5 3 3 3 2.7 ) /4 t ( 2.5 h 2 2 ig e 2 1.8 W 1.5 e g1.5 ra ve 1 A 1

0.5

0

Groups of Indicators

Planning (Moderately; 2.0)

There were written work plans for implementation of CDTI activities in most of the health facilities visited. The plans made adequate provisions for onchocerciasis control activities. In one of the health facilities visited, the plans did not show integration of onchocerciasis activities with the other health programmes at this level. In another health facility visited, the officer was not aware of the existence of a plan he drew himself. This implies that the plans were merely drawn to satisfy higher authorities but were not used for the implementation of CDTI activities.

The plan is only drawn in fulfillment of the demands of the District and Provincial officers. According to the officer, “really we do not have work plan in the health area. But activities are going on as normal. We plan verbally”. In another health centre, the officer said, “when we go up there the coordinator will ask us to plan. We are finding it difficult because we are not used to it”.

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Integration (Moderately, 2.0)

Staff at this level claim to combine activities in implementation. The evaluators however observed an opportunity for demonstrating such integration which was allowed to fritter away because of the inherent attitudinal problem that borders on vertical implementation of activities and resource allocation. There was an opportunity to train for CDTI along with Polio since the same CDDs are used for Polio vaccination and start distribution but staff at this level is waiting for training funds specific for CDTI before they could train for CDTI. This has held up the commencement of Mectizan® distribution.

Leadership (Highly; 3.0)

Some members of the staff at this level take full responsibility for the implementation of CDTI activities while others depend on a push from above to act. A third group awaits a framework from above but now makes decisions within the framework to fit their realities. For instance, a Chief of Post in Fontem Health District said,

…the Provincial Coordinator and DMO give us a time frame within which to distribute. We now decide on our own the particular time that suits us within that time frame

Staff members in some Health Areas await instructions from the District to initiate some activities because of the availability of funds. According to a Chief of Post,

…for some activities, the programme comes from the District, e.g. training because this is influenced by availability of funds. For supervision I draw my action myself.

Generally, staff members here know about CDTI. According to a Chief of Post in Fontem Health District,

…with CDTI here … we do not have any problems. Since the last 2 years the result is increasing. Even the one I brought now people are coming to my house to ask for it. But I said no, until I train the CDDs. There is no severe case. Now people do not come for consultation for blindness.

In Ekondo Titi, the Chief of Post indicated that all nurses know about Onchocerciasis. Leadership here is good. The HA management team is taking full responsibility of CDTI at this level in an integrated manner. The Chairman of Ekondo Titi health management committee demonstrated good commitment.

The Chief of Post in Illor noted that, “the HA staff and management team consider the programme as theirs”.

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Monitoring and Supervision (Moderately; 2.7)

CDDs submit reports of the distribution of Mectizan® to the chief of Post of health centre. The officer in turn submits to the District Health Service. The transmission of reports is within the government system in most health areas. In some health areas, reports are submitted separately and cost paid by the affected programme. So CDTI reports are submitted with funds allocated for training and supervision of CDTI implementation. According to a Chief of Post,

…they give us some money for supervision. From there we fuel our motor cycle if we are going to submit reports. I do the same when I am going to submit for other programmes…. You know that the programmes do not run at the same time. If I have reports for two programmes one will pay going while the other pays for my return….

The FLHF staff members supervise all CDDs routinely. One visit per community is planned in most of the health areas. According to one of the Chiefs of Post, “except there is problem, we visit each community only once in a year”. In some of the HAs CDDs are supervised 2-3 times during one distribution. Supervision is not targeted. In Ekondo Titi, the Chief of Post noted that integrated supervision is carried out generally except during the distribution of Mectizan® because the CDDs could make mistakes.

Problems identified during the supervisory visits were discussed with the CDDs. According to the Chief of Fotabong,

…there is no problem. But if I observe any mistakes I discuss it immediately with the CDD.

Another Chief of Post said,

…when there is refusal I do counsel them on the benefits of Mectizan® and effect on the population if they default…. When the community is doing well I congratulate them on their contribution towards the control of diseases in our communities.

The CDDs inform Chief of Post when there is problem, e.g. severe side effect. Some are resolved, others referred to the Health Centre. The traditional authorities are not involved in problem solving in some of the HAs

Mectizan® Ordering, Procurement and Supply (Highly; 3.0)

In most cases, the DMOs decide on the quantity of Mectizan® to supply to the FLHF. Staff at this level is not allowed or empowered to make requisition for the Mectizan® required. According to a chief of Post,

…I was given 3,000 tablets this year. This is less than the requirement. I would have asked for 4000 if I had done the estimate myself. In some cases there

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were shortages…. Last year (2006) I was given 3325 tablets in instalments. …in 2005 I was given 2000 tablets. Estimate is not usually from the HAs.

Another Chief of Post said,

…I was given 17,850 though I requested 19,000. They said those of us close to the District should take small quantities because it will be easier for us to return for more than our counterparts who stay far away.

Even where the Chief of Post is given a free hand to make estimates of what is required for the health area the estimates are based on wrong formula (10% of the last number of people treated added to the number of people treated in the last distribution period). This points to poor skills in Mectizan® ordering among the staff at this level, which may explain part of the reasons for the usurpation of this role by the DMOs.

Mectizan® is collected with a system that is effective and uncomplicated. However, it is not stored in the system as other drugs used within the health facility. The Chiefs of Post interviewed explained that the system of storage is dictated by the campaign nature of the CDTI programme. They feared that the community pharmacist may not be there when they need the drugs hence the Chief of Post needed to take custody of the Mectizan® while other drugs are kept in the pharmacy. According to a Chief of Post,

…the Pharmacist is a community worker (that is employed by the community). She may not be there when I need Mectizan®. Another reason is that Mectizan® is sent to the District while the Drug Programme brings other drugs straight to the Health Areas.

Another Chief of Post simply rationalized it as a system he inherited. According to him,

It is something that existed before I came to this place. It is that way so that I can get the drug whenever I need it. The person in the pharmacy may not be there when I need the drug.

Training and HSAM (Moderately; 2.3)

There is retraining before every distribution, but this is not targeted at any specific deficiency in the skills of the CDDs. According to one of the Chiefs of Post visited, “we do so in line with instructions from above”

Only the In-charge of the FLHF does the training, which takes place in the health centre. The trainee-trainer ratio is satisfactory. In most cases not more than 20 CDDs were trained in one session by one FLHF staff. In some cases training was used as an incentive to CDDs. Some members of the FLHFs visited, argue that,

…there is need to train new CDDs and even retrain others because of the long time between the distributions. The CDDs may forget and it is the only way of compensating the CDDs.

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Few dropouts were recorded and these were mostly due to non payment of the motivation money promised by the Minister of Health for the past two years.

Some community leaders interviewed were not aware of CDTI while others know and help in sensitization and mobilization. The poor level of awareness is blamed on uncooperative Health Committee members. According to the Chief of Post for Takwai Health Centre, “I sensitize the committees but they don’t carry the news to the people because every body is declaring ignorance of the topics…”.

Another Chief of Post for Fotabong noted however, that he does sensitization of the people. According to him,

…everybody is aware of the programme. HSAM is done during distribution. Letters are given to churches for announcements. I did HSAM last year and the communities agreed to support the CDDs but they have not lived up to it.

Finance (Slightly; 1.0)

Budgets are not normally drawn, but estimates of the cost of some CDTI activities such as the training of CDDs, are made and forwarded to the DMOs. These trainings are financed from the APOC Trust funds. The NGDO partners also contribute to the financing of field activities, and no funds are provided from the government purse for the implementation of CDTI activities at this level in some health areas. The officers at this level blame this on poor financial position of the Health Centres. According to one of the Chiefs of Posts interviewed,

…we are only given running credits for the routine activities in the hospital. Nothing is given for CDTI. But during distribution the DMO gives us some money for training and supervision which we justify after, with the report.

In spite of this the staff at this level could not tell the relative contributions of the different partners for the field operations at this level. This is blamed on the absence of budgeting and poor documentation of funding. According to the Chief of Post for Takwa, “there is nothing like budget here. We do not budget in the health areas. They just decide on what we should do and give us funds for it”.

Transport and other Material Resources (Slightly; 1.8)

Some staff members make use of personal transport for the implementation of CDTI activities. The government did not provide transport for staff. Those without any private transport pay their way to the communities, irrespective of the distance, to supervise distribution of Mectizan®. The situation of transportation here is very despicable. The terrain is rough and tough and villages are far apart.

In the few cases where there are motor cycles which APOC provided, such motor cycles are poorly managed. The control and use of transport facilities are poor because the officers using

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such motor cycles are made to bear to cost of maintenance. The motor cycles are not parked in a pool and are used for personal reasons as well as for the implementation of all health activities in the Health Area.

The Chief of Post for Takwai Health Centre blamed the failure of Government to meet the maintenance cost for the motor cycle on the enlightened choice of the staff at this level to enjoy the motor cycles fully. According to him,

…we are responsible because we do not use log book and park it at the DMO’s office as directed. We want to enjoy it more without knowing that the enjoyment has complications

There is no realistic plan for replacement of the motor cycles. Some hope that APOC will provide them with new motor cycles. According to the Chief of Post in Takwai, “we have no plan for replacement. APOC promised to give us new motor cycles. We have been waiting”.

Human Resources (Fully; 4.0)

As is the case with the District staffing, there is stability of staff in the FLHF. Most of the staff had spent a minimum of five years in their position. However, they lacked skill in the implementation of some CDTI activities such as Mectizan® ordering. However, they demonstrated commitment to CDTI.

Coverage (Fully, 4.0)

Geographical coverage has remained stable at 100% since the 2005 in the health areas visited. In 2005, therapeutic coverage rates ranged from 60.4% to 85.1% with an average of 76.6% (76.6±8.84SD) for those FLHF areas sampled. In 2006, therapeutic coverage rates ranged from 61.6% to 96.6% with an average of 79.1% (79.1±12.67SD) for those sampled. This shows an increase in the therapeutic coverage between 2005 and 2006 distribution periods. However, there was a slight decrease in 2007. The therapeutic coverage in 2007 ranged from 62.0 to 86.4 with a mean coverage of 75.2% (75.2±10.31SD). This decrease is blamed in part on the refusal of CDDs to distribute Mectizan® if they are not paid to do so. All the same therapeutic coverage was consistently >65% for the last three years.

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Recommendation for the FLHF Level:

FLHF Recommendations Implementation Planning Priority: MEDIUM ¾ Written health plan should Indicators of Success: integrate all health programmes at a) Minutes of planning meeting this level b) Existence of integrated plan ¾ Minutes for the planning meetings Who takes action: should be documented FLHF staff/DMO Deadline for completion: End of next distribution in 2008 Integration Priority: MEDIUM ¾ Train staff at this level on record Indicators of Success: keeping a) Minutes of training ¾ Train staff on principles of Who takes action: integration DMO Deadline for completion: January 2008 Monitoring and Supervision Priority: MEDIUM ¾ Target supervision on problem Indicators of Success: areas a) Report of monitoring exercise ¾ Use checklist for supervision Who to take action: ¾ Keep copies of monitoring report in Chief of Post the FLHF Deadline for completion: End of next distribution in 2008 Training & HSAM Priority: HIGH ¾ Conduct CDD training need Indicators of Success: assessment a) List of training needs ¾ Target training on needs only b) Report of training ¾ Train FLHF staff on Mectizan® Who to take action: ordering DMO ¾ Sensitize traditional leaders Deadline for completion: End of next distribution in 2008 Financial Resources Priority: HIGH ¾ Government should finance CDTI Indicators of Success: implementation activities at this a) Payment vouchers for CDTI activities at level this level ¾ There should be proper document b) Records of government contribution of government funds (Health c) Training report Centre Running Credit) used for Who to take action: DMO CDTI activities, as government Deadline for completion: contributions End of next distribution in 2008 ¾ Train staff at this level of documentation

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FLHF Recommendations Implementation Transport & other Material Resources Priority: HIGH ¾ Government should provide Indicators of Success: transport and training materials for a) Payment vouchers for CDTI activities at CDTI implementation this level ¾ Government should meet the cost b) Existence of teaching aids provided by of maintaining motor cycles government ¾ There should be a proper system of c) Existence of motor cycles control of the use of motor cycles d) Existence oflog book to control use Who to take action:DMO Deadline for completion: End of next distribution in 2008 Coverage Priority: HIGH ¾ Conduct HSAM in areas with low Indicators of Success: coverage a) Increased coverage ¾ Sensitize communities to support Who to take action CDDs FLHF staff Deadline for completion: End of next distribution in 2008

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3.4 Sustainability at the Community Level

Fig. 4: SWII CDTI: Sustainability at Community Level 4 4 3.3 3.5 3 3 3 3 ) 3 /4 t (2.5 h 2 2 ig e 2 W ge1.5 ra e 1 Av 0.5

0

Groups of Indicators

Planning (Highly; 3.0)

CDDs are planning and managing their CDTI work efficiently. They make announcements through town criers. They first distribute at a central place and later go to the homes of those who did not turn up for treatment at the central place. Community leaders decided on central place distribution to make the work easier since the CDDs are not paid. CDDs in some communities plan work to make it easier. For instance in Belap and Eselewon communities CDDs said,

…we divide the community into quarters and treat one quarter a day. We go house to house, very early in the morning because the people will not come out to take it if we ask them to come to a central place. We also update our register as we go from house to house for treatment.

However, some CDDs update the registers differently from distribution. No reason was given for this planning. According to a CDD interviewed, “that is how we were trained to do it”.

Leadership and Ownership (Highly; 3.0)

In some communities the leaders take responsibility for distribution within their communities, though there are no community meetings to review happenings related to treatment. In most

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of the communities, the leadership educated those who refuse to take Mectizan®. They give announcement in the market places and churches. According to the Chairman of the Dialogue Structure (Health Committee) in Fotabong Health Area,

…we go out to sensitize the people on the need for Mectizan®. Formally, when it just started they were not responding well out of fear. But with the sensitization they respond well. Some even come before the time to ask for Mectizan®.

In others, the community leadership is not involved. Again, communities were not involved in decision making. In the views of the community members, “the health workers and providers of the drug decide when to bring the drug…”. On the other hand, however, communities select the CDDs and decide on the mode of distribution. All the same, in some communities the health workers appointed the CDDs. For instance in Fotabong Health Area, the Chairman, Health Committee said, “the Chief of Post and some members of the health committee select CDDs because they know who can do the work”.

The CDDs interviewed demonstrated high degree of enthusiasm for their assignment for different reasons. According to a CDD, “the community values the drug. The community members are very happy. Now they complain why have we not started distribution?” A community leader in Ebensuck said,

…if you take the drug your body will be strong. You will work very well on your farm. It gives full power for work. If it rains your skin will not be soaked

The wife of the late village leader in Takwai gave her personal experience. According to her,

…I had filarial in my body and I was using Notezin. Because of the effect of Nobaltin I could not complete the dose. My feet were black. Then I visited my auntie in Yaoundẻ. She advised me to take Mectizan®. I went to the Pharmacy, and bought it for 800cfa. When I returned to the village I saw the drug being distributed free. Since then I have been taking it and my skin is clear now.

The representative of the community leader wondered why the drug cannot be given twice a year. The people are now demanding for the Tablet. “It kills worm and hair lice”. Another community leader challenged,

…go outside there and ask any woman, irrespective of age she will tell you how good the drug is in this community. The people love it.

Monitoring (Moderately; 2.0)

Reports get to the FLHF promptly. In some of the communities, the CDDs collate the reports and submit to the leader of CDDs who then submits to the Chief of Post. The communities do not provide transport in some cases. In some cases however, the council provides funds for transportation to the training venue. The community members in Ebensuck argued that the reason why the community does not assist the CDDs with transportation,

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…is that the community contributes to the health facility…. So the Chief of Post pays the transport cost of the CDDs from the community’s contributions.

Obtaining and Managing Mectizan® (Highly; 3.0)

Treatment records, and interviews, indicate that all eligible persons who wanted treatment got treatment at the time of distribution. Treatment occurs during the period dedicated for it and drug is not held over for those that are not treated during this period due to absenteeism or temporary non-eligibility.

Appropriate amounts of Mectizan® are given each year, though in installments. CDDs collect the medication from the health facility and take the responsibility to arrange their transportation for the collection of medication, be this walking, bicycle, etc. The community does not arrange for transportation, but this does not seem to be a problem for these communities. The Chief of Post gives them money to offset the transportation cost to the training. However, in some cases the CDDs collect drug outside training and no transport is arranged, when they run out of initial supply of drugs (e.g. Afap)

HSAM (Highly; 3.0)

Both CDDs and some community authorities are sensitive to situations that require more information and provide it as much as possible. According to a CDD in Takwai, “the few people who refuse out of fear of side effect are encouraged to take it”. The HSAM has however been unsuccessful in getting the people to support CDDs.

CDDs sensitize community members on the need to own the programme but request outside influence to get the community members realize that the programme has changed. According to one of the CDDs interviewed,

…we sensitize the community members but request that people from outside our community should come and tell the people that there is nothing from government for us in this job. There should be education to let them know that the system has changed.

Another said, “…there is need for a different body like the Chief of Post or the DMO to sensitize the people on the need to motivate the CDDs”.

Financing (Moderately; 2.0)

The CDDs are not supported in cash. A few communities are making plans to begin to support CDDs in doing their farm work. Some community leaders argued that CDDs are not compensated because they are doing community work. According to the community leader in Takwai,

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…there is no support because it is community work. Some times we say we will support the CDDs by going to their farm. It is like being a catechist you do the work with no pay

A community leader in Ebensuck, however said, “…we did not know that we should support the CDDs”

The Chairman of one of the Dialogue Structures interviewed said,

…they do perform well but sometimes they grumble because of lack of motivation. It is now about two years since they have not been paid. The government was paying them but now we have decided that the community should help the distributors at least once in their own farms.

In some of communities CDDs are exempted from community work. An example of such exemption from community labour was noticed in Ekondo Etiti. In Mbakam a fee of 100cfa was paid by each adult as arranged by the Village Chief. In Ossing it was arranged by CDDs and head of quarter to collect 100cfa from each adult treated.

In others nothing is done to support the CDDs. The Village Chief in Afap said, “…the CDDs are workers and we thought they are paid by government so they are doing their work. We were not well informed”.

In Nfuni, the Chief said, “I thought the CDDs were paid by government. Now that I know I am promising to give them a token if the means are available”.

Human Resources (Highly; 3.0)

The CDDs are skilled and good at the job. One of the CDDs in Eselewon said, “…we have been receiving training since 2000”. There are two CDDs for every village. The ratio of CDDs to the population treated is good. Generally, there were two CDDs for an average of 250 persons. All the same in some villages there were as many as 1000 people to be treated by one CDD. A typical example of this was found in Ossing, where the village leader was not aware of anything about the programme.

Frequency of CDD dropout was low. In Ebensuck one CDD dropped and has not been replaced. 1 dropout in Dibonda but was replaced immediately. According to a community leader who is also a CDD, “the CDDs have been trained. There has been no dropout because they are all farmers and live within the community”.

Most of the CDDs professed their love for the job they are doing either because they derive joy seeing the people happy taking Mectizan® or because they are serving their communities. Some of the typical expressions of willingness to continue with the programme are represented in the select illustrative quote below:

…I love my community. I do not want to disturb them. The way they take the drug is encouraging. It gives me joy [CDD in Takwai]

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…if government refuses to pay we will continue because we are the community. The only problem will be if government fails to bring the drug. Volunteering four days to serve our community is not too much. … That is why they selected people from the same community to serve in their communities, so that CDDs will have human feeling for their people [A CDD, speaking on behalf of other CDDs in Fotabong Health Area].

In Mbakam and Ossing the CDDs said they are willing to continue for the good of their people. In Ekondo Nene the CDD said, “I am established in the village and I do not want to move out. I prefer to remain here and help my people”.

In Illor, the CDD said, “I am willing to continue even if they do not pay me anything. I have done it for four years and will not stop so that I can get my people’s right”

All the same, there were few cases of CDDs who would not do the job unless they are remunerated. Examples were found in Ebensuck and Nfuni. According to the one CDD that dropped out in Ebensuck, “I have done it for four years. I will not stop even if I have to do it for more than ten years”. He argued that,

…the new chief of post is too rude and does not care for our welfare. The former chief of post will talk to us gently and even give us things when we work or go for training. This new man talks rudely to us and gives us nothing, hence I stopped.

In Nfuni, the old CDD said “I will not continue if there is no motivation”.

Coverage (Fully; 4.0)

In 2005 therapeutic coverage ranged from 54.9% to 90% with an average of 75.9% (75.9±10.32SD) for communities sampled. In 2006 therapeutic coverage ranged from 50.0% to 90.10% with an average of 74.62% (74.62±12.80SD) while in 2007 the average therapeutic coverage rose again to 75.36% (75.36±10.12SD) with a range of 52.3% to 87.30%.

Though the coverage did not show a clear pattern for the three years under review, one finds that some communities made coverage of less than 65% in the three years. This is a pointer for the areas of concern. The reason for the low coverage in some communities was attributed to the fear of side effect in areas where there is co-endemicity of onchocerciasis and loa loa in Eyumujock.

The evaluation team recommended that steps should be taken to establish the situation with loa loa in the area. Steps should also be taken to allay fears of severe side effects among those that are free of loa loa.

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Recommendation for the Village Level

Recommendations Implementation Planning Priority: MEDIUM ¾ CDDs should be encouraged to Indicators of Success: undertake census update at the a) Distribution report same time with distribution of Who takes action: Mectizan® to reduce work burden FLHF staff Deadline for completion: End of next distribution in 2008 Leadership and Ownership Priority: HIGH ¾ Institute community self monitoring Indicators of Success: ¾ Encourage community leaders to Report on institution of CSM and SHM involve communities in problem Who to take action: solving by holding SHM in FLHF staff communities Deadline for completion: ¾ Encourage communities to support End of next distribution period in 2008 CDDs Monitoring Priority: MEDIUM ¾ Community leadership should Indicators of Success: arrange transport for CDDs to Transport provided for CDDs where necessary submit reports Who to take action: Village leader and FLHF staff Deadline for completion: End of next distribution in 2008 Obtaining and Managing Mectizan® Priority: HIGH ¾ Mectizan should be kept at the Indicators of Success: FLHF for treatment of absentees 1. Report showing that Mectizan® was and temporary ineligibles kept for the treatment of absentees and ¾ Communities should arrange temporary ineligible transport for CDDs in distant 2. Transport provided for CDDs in distant location to collect Mectizan® for locationa their communities Who to take action: Community leaders and FLHF staff Deadline for completion: End of next distribution in 2008 Financing Priority: HIGH ¾ Sensitise communities to their roles Indicators of Success: in CDTI implementation, especially Evidence of community financial support for on financial support for the CDTI implementation programme Who to take action: FLHF staff Deadline for completion: End of next distribution in 2008 Human Resources Priority: HIGH Encourage communities to select more Indicators of Success: CDDs and reduce work load for the More CDDs selected

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Recommendations Implementation existing CDDs Who to take action: FLHF staff Deadline for completion: End of next distribution in 2008 Coverage Priority: HIGH Indicators of Success: ¾ Conduct HSAM in areas with low Increased coverage in communities currently coverage to educate the people on experiencing low coverage the benefit of taking Mectizan® Who to take action: ¾ Screen communities that are feared DMO/FLHF staff to have co-endemicity of Deadline for completion: onchocerciasis and loa loa End of next distribution in 2008 ¾ Make provision for drugs in managing severe side effects ¾ Train FLHF staff on management of severe side effect

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3.5 Comparative Analysis of the Sustainability of the Four Levels

All scores awarded during the evaluation to the SWII CDTI project for the various sustainability indicators groups are shown in Table 2. The overall score was 2.85 points. The FLHF has the lowest average score for CDTI implementation (Figure 5). The FLHF scored ‘Moderate’ (average 2.50) compared with other levels which clustered around the “High’ sustainability potential rating (2.86-3.14).

Table 2: Average Sustainability Score of the Different Groups of Indicators by Levels of CDTI Implementation in SWII CDTI Project Levels Groups of Indicators Planning Planning Integration of support activities Leadership Monitoring & Supervision Mectizan® supply Training & HSAM Finances Transport Human Resources Coverage Average Community 3.00 -- 3.00 2.00 3.00 3.00 2.00 -- 3.30 4.00 2.91 FLHF (HA) 2.00 2.00 3.00 2.70 3.00 1.50 1.00 1.80 4.00 4.00 2.50 District 3.00 3.00 4.00 3.00 3.00 2.30 1.30 1.50 3.50 4.00 2.86 Project 3.00 4.00 3.00 4.00 3.00 3.30 1.30 2.30 3.50 4.00 3.14 Average 2.75 3.00 3.25 2.93 3.00 2.53 1.40 1.87 3.60 4.00 2.85

The weakest groups of indicators for the FLHF level included finance (1.0), transport (1.8) and monitoring and supervision (2.7); and highest score (4.0) was awarded for coverage in the FLHF level.

Fig. 5: Average Performance of the Different Levels of SWII CDTI Pooled Groups of Indicators

3.5 3.14 2.86 2.91 2.85 3 2.5 4) 2.5 (/ t 2 gh ei 1.5 W e 1 ag 0.5 er v 0 A

Levels

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Values from Table 2 are further shown graphically in Figure 6. The Health Area (FLHF) level was weak in planning. The weakest point for the District was in finance. The community level’s weakest areas were finance and monitoring. Generally, finance was the weakest of all the groups of indicators. Transport and other material resources, then of course monitoring and supervision follow this.

Mean sustainability scores for the groups of indicators are shown graphically in Figure 7 below. The weakest groups of indicators, overall, were the provision of Finance (1.40), followed by Transport/Material resources (1.87), Training and HSAM (2.53). These findings are good reflections of the performance of the groups of indicators in the eight year. All the same it is a remarkable improvement on the 2003 situation. The Evaluation Team made important recommendations in all of these areas. These concerns are addressed in the post-APOC sustainability plans prepared in order to move the project towards being fully sustainable as APOC support ceases finally.

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Fig. 7: Average Performance of Each Group of Indicators in the Entire Project

4 4 3.6

3.5 3.25 3 2.93 3 3 2.75 ce 2.53 an 2.5 rm fo 1.87 er 2 P e 1.4 g 1.5 ra ve A 1

0.5

0

Group of Indicators

The box plot below shows the actual performance range of the different groups of indicators across the four levels of SWII project administration. It gives the actual performance range, which cannot be discerned from the bar charts. Mectizan® supply and Human resources were constant and lacked variability in the performance of these groups of indicators across levels. For the other groups of indicators, there were wide ranges of performance, hence the need to highlight this in the box plot.

The box plot shows that finance and transport did not only performs poorly, but the performance across the four levels for these groups of indicators range from a low 1.0 and peak at approximately 3.0 score. The median score for these groups of indicators is <2.5 for finance and transport across levels. Similarly, the median score for planning group of indicators and M&S is >2.5 points. Fifty per cent of the different levels of the project implementation scored less than 3.0 on planning.

On the other hand, coverage and human resources were the strongest points of the project area. The community members expressed satisfaction with Mectizan®. In many cases they demonstrated the strength they gained from taking Mectizan®. In some cases, the people wondered why they would not be allowed to take the drug twice in a year for greater and sustained effects of the drug in the body.

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Similarly, the personnel involved in the handling of Mectizan® at all levels are happy with the programme. For most of them, satisfaction with the programme derives from the fact that it has provided them with the tool to do more work. At the community level, the satisfaction derives from the joy they observe on the faces of those who take the drug. They are happy to be associated with that which brings joy to their people.

Performance on Fig. 8: SWII CDTI Project: Performance of Groups of Indicators integration and Training and HSAM 4.0 varied greatly among the different levels of 3.5 implementation of CDTI. For instance, sustainability 3.0 performance on integration ranged from as low as 2.00 2.5 points in the Health Area (FLHF) level and 4.00 points at 2.0 the project level with a median score of 2.7 points. This 1.5 shows that while CDTI is fully integrated at the 1.0 project level, it is not

P In L M M T F T H C so integrated at the la t e o e H in ra u o n e a n c S a n m v n g d i t A n s a e Health Area (FLHF) i ra e to iz M c p n ra n t rs r a e o g g io h in n r e n ip g t level.

Similarly, the sustainability performance on Training and HSAM varied from as low as 1.50 points at the Health Area (FLHF) level to as high as 3.3 at the project level with a median score of 2.40 points in the entire project areas. The FLHF level staff still need to intensify HSAM and target training for greater results in the implementation of CDTI in the project area.

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4.0 CONCLUSION

4.1 Grading the Overall Sustainability of SWII CDTI Project.

Making a judgment of the project in terms of the seven aspects of sustainability

(a) Make a judgment of the project, in terms of each of the seven ‘aspects’ of sustainability:

Judgment: to what extent is this aspect Aspect helping or blocking sustainability in this project? Integration HELPING Resources BLOCKING Efficiency HELPING Simplicity HELPING Health Staff Acceptance HELPING (Attitude of staff) Community ownership BLOCKING Effectiveness HELPING

• Integration

There was an adequate amount of integration of CDTI into the health systems at all levels of the project implementation. Every body in the District and FLHF levels know about CDTI. Staff at the project level combined diverse programme tasks on each single trip to the health district. CDTI activities are part of the minimum package of health care activities. The resources of the health management teams at the different levels were pooled and used in common for all programmes including CDTI.

• Resources (Human, Financial and Material)

The staff is skilled and committed though inadequate in terms of number at all levels. Government financial contribution has so far been minimal and limited to payment of salaries and CDD compensation. Transport at the lower levels is grossly inadequate and poorly managed or maintained. Government does not meet the running costs for transport. There is over reliance on support from APOC and SSI for field activities. Over reliance on external sources could block sustainability.

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• Efficiency

Though activities like training and monitoring and supervision are not fully justified at the District and FLHF levels, there is a rational use of available resources. Programme support activities are planned and resources shared, which results in lower cost and efficient management of resources. An example is the sharing of logistics. For instance, at the Provincial level planning for supervision and trainings are based on needs.

• Simplicity

The project uses simple and uncomplicated procedures for the implementation of CDTI activities. For instance, the ordering, procurement and supply of Mectizan® is very simplified. Similarly, the process of accessing funds for CDTI activities is very simple.

• Attitude of Staff

At all levels, there is ample evidence that the staff members are positively disposed to continue CDTI implementation. Generally there is high level of commitment demonstrated among the health staff. The Evaluation Team rated the attitude of staff at all levels towards CDTI to be very positive.

• Community Ownership

Communities welcome the drug and are willing to take Mectizan®. They are quick to mention the social and health benefits of taking Mectizan®. The people are increasingly demanding for Mectizan® and in some they want to take it twice in a year. However, communities are not empowered to make the decisions on the implementation of CDTI. The health workers select the CDDs. In many communities visited community members demonstrated ignorance on their roles to support the CDTI process by supporting the CDDs. The programme is seen as government programme and Government is expected to pay the CDDs, where this fails CDDs threaten to stop distributing Mectizan®. Worse still, community leaders and traditional authorities are not sufficiently sensitized and involved in problem solving. The evaluation team considers this, a serious block to sustainability and recommends HSAM activities targeting the communities and their members to sensitize them on their roles in CDTI.

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• Effectiveness

Geographical coverage rate has remained 100 per cent since 2005 at all levels of implementation. The therapeutic coverage rate is >65 percent, and on a steady increase at the Provincial and District levels while the drop witnessed at the community level in 2006 has been cancelled by a further rise in 2007 (see Figure 9). All the same one is not certain what will happen at the end of 2008 distribution period with threats to stop distribution if Government fails to pay the CDDs for the 2006 and 2007 distribution periods.

All the same, the evaluation team considers the current coverage rates to be helping sustainability because it has remained >65% and the people are increasingly demanding Mectizan® having realized the benefits. In Mamfe Health District people are already taking steps to pay CDDs in some of the rural communities while in Mamfe community the people are trooping to the health facility to be given Mectizan®.

(b) Next, the Evaluation Team examined the five key aspects of the project – ‘critical elements’ of sustainability. If these are not present it is unlikely that the project will be sustainable:

ƒ Money: Is there sufficient money available to NO undertake strictly necessary tasks, which have been carefully thought through and planned? (Absolute minimum residual activities). ƒ Transport: Has provision been made for the NO replacement and repair of vehicles? Is there a reasonable assurance that vehicles will continue to be available for minimum essential activities? (Note that ‘vehicle’ does not necessarily imply ‘4x4’ or even ‘car’). ƒ Supervision: Has provision been made for continued targeted supportive supervision? YES (The project will not be sustained without it).

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ƒ Mectizan® supply: Is the supply system YES dependable? (The bottom line is that enough drugs must arrive in villages at the time selected by the villagers). ƒ Political commitment: Effectively YES demonstrated by awareness of the CDTI process among policy makers (resulting in tangible support); and a sense of community ownership of the programme.

Money

The project lacks sufficient money to undertake necessary CDTI activities, hence it scored 1.4 points. As APOC funding is decreasing the Government funding is not increasing to cover the shortfalls. Unfortunately, the NGDO has not been able to fill the gap created by the decrease in APOC funding supports. Worse still, the implementers of the project at all levels are not able to mobilize funds outside APOC and the NGDO to finance implementation of CDTI activities. Much of the funds from government is for the payment of CDDs at the community level. It is thus recommended that government be sensitized to re-channel its funds to the implementation of CDTI activities at the health service levels while the communities are sensitized to take on their responsibility of supporting the CDDs.

To appreciate government contributions to the project the amounts were multiplied by a factor of ten so that the line curve could rise above the base. The actual amounts of the different partners are contained in Table 3 below.

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Table 3: Actual Contribution of Partners to SWII CDTI Project Implementation in US$ since Inception (2000/2001 to 2008)

Year AMOUNT RECEIVED TOTAL APOC SSI NOTF MOH PDPH (US$)1 (US$)2 (US$) (US$) (US$) YEAR 1 235,857 45,857 -- na3 281,714 YEAR 2 117,182 32,350 -- na 149,532 YEAR 3 92,499 41,288 -- 9,156 na 142,943 YEAR 4 27,208 52,057 541 9,215 na 89,021 YEAR 5 26,291 83,375 601 9,898 1,308 121,473 YEAR 6 17,142 45,796 361 Exp4 2,400 65,699 YEAR 7 1,048 43,277 180 Exp 1,709 46,214 YEAR 8 16,808 28,931 -- Exp 630 46,365 TOTAL 534,035 372,931 1,683 28,268 6,047 942,964

Government funding for CDTI at Provincial and District levels has improved from what is was in 2003. Before 2003, Government did not make disbursements for CDTI field activities. Between 2003 and 2008 the MoH spent $28,268.00 on the SWII CDTI project. However this money went mainly for payment of compensation for CDDs. In addition to this, Government also paid salaries of the health staff as well as made provision for stationeries and transport as well as running credit for the health centers which are sometimes used for CDTI field activities like submission of reports. This comes as a reflection of the integrated use of these resources in the health departments.

Government funding support was categorized into direct and indirect. The amount stated above is the direct funding government provided for CDTI implementation. It has also made some indirect funding of the SWII project through supports for supervision passed through the NOTF to the project. Between 2004 and 2008 government disbursed $1,683.00 to the project coordinator to help with supervision in the project. The Provincial Delegation for Public Health maintains the capital equipment and vehicles and spent between 2005 and 2008.

All the same the major funding for CDTI is from external sources, specifically APOC and SSI. Between 2001 and 2008, SSI provided technical and financial support of about $372,938.00 and still plans to give another $197,115.39 for the coming four years (2009-2012). APOC, on the other hand has committed $534,035.00 and other technical assistance to the project since inception.

1 APOC also supplied other capital equipment and non financial support 2 Exchange rate used was US$1.00 to 416cfa 3 na=not available due to poor documentation 4 Exp = still being expected. Budget approved yet to be released

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Transport

Provision has not been made for the replacement of vehicles. Every person interviewed declared the inability of government to replace the vehicles used for implementation of CDTI at all levels. Routine presumptive maintenance of the vehicles are lacking in the project. Vehicles are only repaired when they break down or when the health service needs them for any major activity or campaigns. The Delegation repairs and maintains vehicle at the Provincial level. However, individuals using the vehicles repair them, when they break down at the lower levels. The project was thus scored 1.87 on transport for the foregoing reasons.

Supervision

Adequate provision has been made for supportive targeted supervision in the project at all levels. With the integration of CDTI and Eye Care programme the project is well positioned to conduct supportive supervision of CDTI in areas of weakness as the Eye programme is undertaken. Moreover, the health service has also a unit of supervision and monitoring which provides support for CDTI supervision. The project was scored 2.93 points on supervision.

Mectizan®

There is always sufficient amount of Mectizan® in the project, which also arrives the communities early. The process of ordering, procuring and supplying Mectizan® is uncomplicated and very efficient. The Provincial Drug Programme procures and manages Mectizan® along with other drugs in the Province. It was thus scored 3.0 points.

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Flow Chart 1: Mectizan® Flow in SWII CDTI Project

Political Commitment

The policy makers in the health service are committed to CDTI implementation. CDTI is considered part of the minimum package for health in the country. The Ministry of Health has consistently lived up to its promise of paying the CDDs to increase compliance in the communities. It is however recognized that this does not promote community ownership of the programme and threatens sustainability. All the same, this is a demonstration of the commitment of policy makers to the eradication of onchocerciasis as a disease of public health importance in the communities.

The communities have not assumed ownership of the CDTI. They fail to support the CDDs. When asked why they do not support the CDDs, since they recognize the benefits of taking Mectizan® and demand to be treated every year they plead their ignorance on the need for

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community to support CDDs. They are always quick to note that government pays the CDDs for their work.

The policy makers in the health service recognize this weakness at the community level and are planning sensitization activities to exploit the present high demand for Mectizan® and shift the responsibility of supporting CDDs to the communities and make the communities own the programme. The project was scored 3.25 points on leadership, which approximates to political commitment among the groups of indicators.

In line with the guideline for grading the whole project using the seven aspects and five critical elements of sustainability the Evaluation Team concludes that the SWII CDTI project is MAKING SATISFACTORY PROGRESS TOWARDS SUSTAINABILITY. Two of the elements, transport and supervision were not dependable. Two of the aspects, resources ad community ownership are blocking sustainability.

The quantitative score of 2.85 also supports the qualitative decision which holds that the project is making satisfactory progress towards sustainability.

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4.2 Comparison of the Project Performance during 2003 and 2008 Evaluations following Implementation of the Recommendation of 2003 Evaluation Team

Having graded the project for its sustainability potentials in the 2008 evaluation exercise, the evaluation team proceeded to assess the level of improvement that has occurred in the project since the 2003 evaluation and following the implementation of recommendations of the 2003 evaluation team. The results of this assessment are contained in Figure 10 below.

Figure 10 revealed a general improvement in the sustainability performance of the project on all the groups of indicators, with the exception of planning, training/HSAM and transport. The project was found to have declined from 2.88 points in 2003 to 2.75 points in 2008 on planning. It also dropped from 1.97 points in 2003 to 1.4 points in 2008 on transport and from 2.73 points in 2003 to 2.53 points in 2008 on T/HSAM.

On the other hand, the project recorded appreciable improvements on the other groups of indicators between 2003 and 2008. In 2003 the project scored 1.0 point on integration but improved to 2.25 points in 2008. Leadership was another group of indicators on which the project recorded improvement between 2003 and 2008. In 2003 the coverage score for the project was 1.7 whereas the score in 2008 was 4.00 points. The case was the same on Mectizan®, rising from 2.13 in 2003 to 3.00 points in 2008 and finance rose from 1.03 points in 2003 to 1.40 points in 2008. On the whole the project sustainability score rose from 2.17 points in 2003 to 2.85 points in 2008.

It bears reiteration to note that the project recorded some improvements on finance from the situation in 2003, irrespective of the poor financial contributions of government towards the implementation of support CDTI activities. A remarkable change in the financial position of the project, in response to the recommendations of the 2003 evaluation is in the simplification of the process of accessing funds available for CDTI implementation. The evaluation team in 2003 found that the process of accessing funds for CDTI implementation was very complicated as the implementers had to go through a circuitous and tortuous process to access funds to support activities. Prior to the 2003 evaluation exercise, the team had to make seven excruciating contacts outside the project area before accessing funds (see Chart 2). This was reduced to one simple contact with the NGDO in Youndẻ before the 2008 evaluation exercise (see Chart 3).

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Flow Chart 2: Process of Access Funds for CDTI Activities

OPC in Buea makes request to PDPH sends endorses SSI CR in Yaoundẻ studies and APOC finance approves officer in Younde OPC raises conducts cheque to PDPH PDPH signs SSI CR approves in APOC finance Yaoundẻ officer in Younde pays to Funds get to joint APOC/SSI joint OPC raises Account APOC/SSI cheque to project account be drawn on the PDPH in account in BUea signs cheque SSI Rep. in OPC withdraws Limbe funds from joint signs APOC/SSI project Account

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By 2003 the APOC finance officer was resident in the SSI country office in Yaoundẻ and operated the financial transactions of the project in Buea from that point. The evaluation team in 2003 observed that this does not help sustainability as it strengthens the threat to sustainability of the Flow Chart 3: Process of Accessing Funds for project. It also made the implementation OPC raise process to be complex request for and inefficient. Worse still it did not promote funds for ownership of the project by the SSI Delegation. The issues a leadership of the signed Delegation did not have knowledge of what is Delegate available for CDTI receives the implementation. The signed cheque APOC finance officer from SSI and was seen as a staff of APOC finance SSI and this strengthened the officer cashes the perception of the cheques from project as SSI project. APOC or SSI In 2008 the evaluation team observed that the APOC finance officer had been transferred to Buea as recommended. The Delegation provided the APOC finance officer with an office space from where he operated the APOC account within the Delegation for public health in Buea.

However, SSI paid the salaries of the finance officer. Thus, he was not answerable to the leadership of the Delegation. This was identified as a weakness in the project implementation even in 2008. All the same, leadership, which was lacking in the project in 2003 received a boost. The policy makers in the Delegation have now realized that the project belonged to the Delegation and took steps to assume ownership. They now plan and undertake activities independently. Both the SSI staff and the leadership of the Delegation, interviewed were agreed on the fact that the Delegation no longer waited for a push to initiate activities in the project.

Figure 11 below revealed movements in performance levels of the different levels of implementation of CDTI in the SWII project area. It showed, for in stance, that with the exception of the front line health facility (FLHF) level, there is a general increase in sustainability performance on the levels of implementation. The FLHF experienced a decline in performance from 2.64 points in 2003 to 2.50 points in 2008.

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On the other hand, the Provincial or project level rose from a very low 1.92 points in 2003 to a very high 3.14 points in 2008. Similarly, the District rose from 2.11 points to 2.86 points in 2003 and 2008 respectively while the community level appreciated from 2.00 points in 2003 to 2.91 points in 2008.

The Paradox here is that the FLHF which was the strongest point of the project in 2003 turned out to be the only level that suffered a decline in 2008. This was attributed to the routine nature of implementation with proper justification of support activities. For most of the FLHFs visited, integration was weak and the involvement of community leadership was very low. Opportunities that existed for integrated implementation of support activities were not used. Instead, some FLHF staff insisted on vertical implementation of activities.

The improved leadership roles of the policy makers at the Delegation, the level of integration, targeted monitoring and supervision and the improved coverage recorded in 2008 over the 2003 scores, among others pushed the provincial or project level up on the sustainability ladder. Similarly, the interest in Mectizan® due to the successful HSAM activities of the health service to improve coverage helped the sustainability potentials of the project at the community level.

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4.3 Feedback/Planning Meetings

One joint feedback/planning meeting, for Provincial and District level teams was successfully organized. The objectives of the workshop were as follows:

1. To give feedback on the evaluation findings by the Team of Evaluators 2. Discuss the findings among the implementers, the policy makers and the Team of Evaluators 3. Discuss the concept of sustainability in relation to the SWII CDTI project 4. Develop plans for the sustainable implementation of SWII CDTI for the coming five years

The workshop lasted for three days. The programme is attached.

The sustainability plans, developed from the feedback/planning meetings will be forwarded together with the necessary justification when they are duly signed by the appropriate authorities. These will be forwarded, with the necessary accompanying documents to APOC by the project through the NOCP at a later date.

Below are some key issues and comment that emerged after the briefing session. These concentrated primarily on the provision and use of resources. Others were managerial and documentation issues. Planning was also weak. The evaluators also highlighted the problem with declining coverage in one health area in Eyumujock Health District as well as low integration in some Health Districts.

Training was not targeted and in most cases. Record keeping was also identified as a weakness. The running and maintenance of vehicle and other capital equipment were dependent on non- government sources. This is not sustainable. Community ownership of the programme was largely absent in the project. Communities failed to support CDDs and Government paid CDDs for distribution of Mectizan® in the communities. For the last two years (2006 and 2007) Government has been unable to pay and CDDs are beginning to complain. Some CDDs have actually refused to distribute Mectizan® for the 2008 distribution period.

Opening the floor for comments the Provincial Chief of Unit (Supervision, monitoring and evaluation) said,

CDTI has not only brought us closer to the communities but has helped us to do a lot of things better…. The team (evaluators) has done well. We have been able to get what actually happened.

She proceeded to call on participants at the workshop to react to the observation of the evaluators.

Reacting to the observation that the low coverage in Afap health area was due to shortage in the supply of Mectian®, the DMO Eyumujock noted that the real problem in Eyumujock was not the shortage of Mectizan®. According to him,

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…the problem of Afap area is that two villages failed to carry out distribution of Mectizan®. They had no CDD. We had to go to Ogomoko and Mbatum to request them to give us CDDs to distribute the Mectizan®.

On the issue of government funding of CDTI field activities, the participants blamed the seeming poor government funding of CDTI activities on improper documentation of government contributions. There was a consensus that the government allocates running credits to the health centers and the sometimes, due to the level of integration the health staff spend part of their running credit on CDTI, but are unable to document this. According to the SSI country representative,

…finance scored low because we do not know how to allocate our resources. There is running credit. Some of the funds you (referring to the District Health Service staff in the workshop) use for training are not from APOC and SSI. We do not adequately recognize government contribution. We need to be able to carve out money from what government gives that we use for programme implementation.

Putting it succinctly, the OPC blamed the situation on documentation. According to him, “everybody has been putting in something but it is problem of documentation”. The Provincial Chief of Unit (Supervision, monitoring and evaluation) agreeing with the others who spoke earlier said,

…Government is giving running credit. CDTI is a programme that has led the way for us to do thing better. It is left for the Chiefs of Post to allocate the running credit for CDTI. Government has already given money for running the service. It will not give any credit specifically for CDTI

The DMO for Eyumujock however lamented that, “those who are using the money are not capable of evaluating what government contributes. The difficulty we have is to put it in proportions or percentages”.

On CDD compensation, the Provincial Chief of Unit (Supervision, monitoring and evaluation) noted that,

…what government is doing now is a source of concern. We are also looking at ways of doing it better but it will take a lot of HSAM. The government funds for now are used for motivation of CDDs. We are thinking of how to get the communities to think. We are looking at how we can get the communities to take ownership. We plan to have health center workshops where the community members will work together with the health service to see how we can sensitize the community to take ownership of the programme…. With the CDTI plan for sustainability we should be able to boost what we have started….

Still on community ownership and following from the speech of the Provincial Chief of Unit (supervision, monitoring and evaluation) the SSI country representative emphasized that,

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…. The big problem we have at the community level is that we have put too much responsibility on the CDDs. Sensitization and community meetings should be facilitated by the Health Center staff. This is not done in most communities.

Some of the DMOs gave their experiences with the communities they work in. The first to speak was the DMO Akwaya Health District. According to him,

…some community leaders are sensitized severally but they do very little for the CDDs. The reason is that they command very little respect among their subjects.

While most of the other DMOs present agreed with him, stressing the weak authority of the community leaders over the people in contrast to what obtains in other parts of Cameroon, the Northwest province for example, it was reported that the community leaders in Mamfe have been able to get their people to support the CDDs. According to the DMO Mamfe,

…the situation of Mamfe is revolving. The CDDs refused to distribute Mectizan®. It has even affected the Polio programme because the CDDs said they did not trust government anymore and will not participate in any health programme unless they are paid. But in one of the communities the people gave each CDD 10,000 cfa and distribution is going on now. In Mamfe town it is different. Since the CDDs refused to distribute Mectizan® the people are coming to my office to take Mectizan®.

Finally, it was resolved that there should be sensitization of the communities to take ownership of the programme and support the CDDs to distribute Mectizan®. At the same time, steps will be taken to re-channel government funding to supporting field activities rather than motivating CDDs, which is seen as a threat to community ownership and sustainability.

Closing this section and introducing participants to the section on articulation of solutions to the problems discussed earlier and other issues raised during the feed back on the evaluation, the provincial Chief of Unit (supervision, monitoring and evaluation) said,

… I am happy with what we are doing because we are going into the qualities of what we are doing. Now we know who should do what…. We are going now for quality not for generality. We know who is doing what and who should do what…. CDTI is always opening our eyes to many things.

The group proceeded to do the SWOT analysis of their project area. They identified the strength, weaknesses which were mostly those highlighted by the evaluators. They also proceeded to identify the threats to CDTI sustainability. They further identified the opportunities for countering the threats and taking CDTI implementation to a level of full sustainability in the next five years (see appendix II).

Next they proceeded to identify solutions to the weaknesses identified on the implementation of CDTI. This was done for all the levels of CDTI implementation (see appendix III). Finally they developed a five year sustainability plan for the Provincial and Health District levels.

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4.4 Way Forward

On the way forward, the Provincial Delegate thanked the evaluation team. He gave a speech which focused largely on what the Southwest Delegation of Public Health has been doing, what it plans to do given the opportunities that are coming its way and of course the constraints. According to him,

…the province is happy that the evaluation has come; the evaluators have seen and made recommendations. Certain indicators, which have appeared as hiccups need to be addressed immediately in the entire health care delivery system…. The problems might be the same for all other vertical programmes. The government of Cameroon has recognized it and is proposing to address them in the Sector Wide Approach (SWAP). The French, German and World Bank as well as WHO, UNICEF are working towards this SWAP to integrate resources etc. for health care delivery. We are still very indebted to APOC and SSI with respect to capital equipment and funding. I believe you have worked hard in developing sustainability plans to address the problems identified.

After the Delegate, the participants were allowed to express themselves on any issues bordering on the evaluation as well as the implementation of CDTI within the SWII project area, past and future. The SSI country representative was the first to speak. In her speech she said,

…for SSI, even if APOC stops funding the programme SSI will be there because river blindness is within the Eye Care programme…. SSI will no support everything but will do anything to ensure Mectizan® gets to the stomach of the community members. SSI will organize resource mobilization training for the SWII CDTI project implementers to enable them mobilize other resources for CDTI implementation.

The representative of the National Coordinator, NOCP, pledged to ensure timely arrival of funds if funds received are adequately and promptly justified. Next, was the turn of the DMOs to express their feelings on the programme. The DMO Mundemba was the first to speak. In his speech, he said,

…this forum has been very illuminating and rewarding for us especially as this planning is concerned. There were many things we were doing, e.g. planning for the sake of planning and routinely. This forum has sharpened our focus. We pledge that with support from partners we shall be there to do the work in spite of the shortage of staff.

DMO Eyumujock said, … I feel that the three days we spent is enriching. The first thing is that we shall download the information we gained here to the Health Areas…. In the next five years we shall mobilize the communities to take over the programme. We shall play only the role of assisting them to carry out the programme. Eyumujock has problem with Ogurah HA so we solicit support of partners to design programme to address these problems….

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DMO, Wabane …. I am glad to have participated in this programme. Wabane is very new even though CDTI is not new to the people there. We have certain problems. Most of the actors in CDTI implementation lack knowledge of the CDTI philosophy. Secondly, it is a District with only new personnel. They lack skills. So we need support to build capacity in these areas. I am very glad being here because I had no experience in planning before now. I have gained from this….

DMO Ekondo Titi …. We are fortunate to have received one of the evaluation teams in our District. During the evaluation we were made to appreciate the need to plan for specific activities. When I go back we shall train the HA staff on how to draw realistic plans during the next coordination meeting. Although the communities are showing greater interest, we still have problems in Kumbe village where about 25% is still refusing treatment with Mectizan®. This exercise has helped me to think out effective HSAM to address the issues.

DMO Akwaya …we want to appreciate those who called to get first hand information and discuss the findings with us. We have come up with a 5 year sustainability plan. Our main challenge is to get the communities to own the programme. There is high demand for Mectizan® but communities still think it is government programme. We shall work to get more communities to support CDDs…. The attitude of the local leaders is a hindrance. But now we have a new breed of proactive leaders in the council. We shall exploit the opportunity to push CDTI implementation forward. One of the things we got from here is to involve everybody n the DHS in the implementation of CDTI. We shall do that. With respect to capital equipment, Akwaya is a difficult terrain so we shall be needing support in the form to transportation….

DMO Fontem …after the evaluation and feedback…I will be able to orientate my team on what the programme ought to be not what the staff want. We started the campaign for community ownership. This meeting has proved that we were on the right part. So we shall go back to reinforce it. We are soliciting support from our partners to prosecute this task effectively.

DMO Mamfe …I will start by thanking those who conceived this programme. Having worked with CDTI for a long time I have seen the overflow of the benefits being borrowed by other programmes. CDTI has been leading with others following. APOC and SSI have greatly empowered us. CDTI in Mamfe is not a problem. We have had a very dynamic SDO who has taken his Mectizan® in the open field for the past four years. This has made the community members to see CDTI as a gift from God. However, there was an incident of a woman giving Mectizan® to her two year old baby believing that Mectizan® cures all illnesses. The baby died. I am yet to address that. There is also the problem of CDDs refusing to distribute Mectizan®. However, the

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community members are now coming to the health centre to take Mectizan®. Some are however compensating their CDDs.

DMO Bakassi This is our first experience. As I have noticed, we used to put the chart before the horse. But with this meeting we are getting refocused. This meeting has helped us to draw some plans which we shall take as a challenge to implement conscientiously.

Closing the meeting, the Provincial Chief of Unit (supervision, monitoring and evaluation) remarked that the meeting has been wonderful. She thanked APOC and appreciated the opportunity given the DMOs to express their feelings about the programme, as the way forward for CDTI in SWII project is articulated. She went further to say that she finds

…the comments of the DMOs very interesting. This forum has helped us to know that we have been joking. Planning is taken seriously now…. I want to say here that in the appraisal meeting we did here we also carried out SWOT analysis. Each person has been given responsibilities depending on our levels. We were talking of health development plans. This meeting has helped us to know what we are doing. Before, we were planning for another person. This meeting has helped us to acknowledge our shortfalls.

As the SWII CDTI project in Cameroon moves over the period for APOC-guaranteed support the team of evaluators and the ‘programme managers’ made a critical appraisal of the issues that need to be addressed in the short- and medium-terms to ensure the sustainability of the project post-APOC. The following are highlights of the seven critical components of the “way forward” outlined at the joint final session between the external evaluators and the operators of the SWII CDTI project.

1. Documentation: An important area of deficiency that needs to be tackled in order to enhance the sustainability of CDTI is the relative lack of expertise in report writing by the implementers at the lower levels in the project. This is with special reference to documentation of government contribution to the project implementation. A series of workshops at the level of the Districts and Health Areas that address this shortcoming is highly desirable.

2. Resource Mobilization: By mutual agreement the contribution of the various stakeholders to the sustenance of the SWII project post-APOC is a major challenge. It was agreed that the Provincial and District Teams should take advantage of the SWAP to plan and provide resources, both financial and material for the sustainable implementation of the project. The commitment of all to this element of the programme was emphasised and would be given appropriate prominence in the post-APOC plan of operations. Further to this, the SSI has undertaken to train the implementers on strategies for resource mobilization to reduce dependence on donor funds

3. HSAM: In recognition of the poor sense of ownership of the project at the community level, it was resolved that high powered HSAM activities supported by staff from the District and Provincial levels should be undertaken to sensitize the community members

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on their roles in CDTI. The need for intensification of HSAM is further strengthened by the surrounding Mectizan® in the Ogurah Health Area of Eyumujock. The area is endemic of loa loa and onchocerciasis. The strong fear of side effect makes it difficult for the people to receive treatment. The result is that only 3 of the 15 communities that should be receiving treatment in the Ogurah health area do that now.

4. CDD Compensation: There was a mutual agreement on the dangers of the current practice where Government pays CDDs for distributing Mectizan® in their communities. This was seen as a threat to sustainability of the project. To address this imminent threat, it was agreed that steps should be taken to sensitize government on its roles in CDTI and re-channel such funds to supporting the activities at the Provincial and District/Health Area levels, while the communities are sensitized to take on their responsibility of supporting the CDDs.

5. Re-orientation of Health Staff: Following the observation of the evaluation team on the dissatisfaction of some health staff at the District and Health Area levels following the withdrawal of APOC allowances, it was thought fit to undertake a re-orientation of the health staff on the APOC philosophy as well as train new health workers in the new created Health Districts on APOC philosophy and CDTI strategy. The complaints against the withdrawal of APOC allowances are a clear indication of poor understanding of the APOC philosophy among some health staff. This needs to be addressed in the short term to ensure the proper implementation of the plans for sustainability of the SWII CDTI project.

6. Recruitment of a Government Staff and Project Finance Officer: It was also agreed that the Delegation should assign one of its staff as the project finance officer. The old practice where SSI recruited and paid the salaries of the project finance officer mere sustains the rejected principle and practice of vertical programming within the public health system. Such a finance officer naturally would not be answerable to the leadership of the Delegation. This also negates the principle of ownership of the project within the Delegation which it is meant to serve.

7. Operations Research: The evaluation team also found the new enthusiasm to take Mectizan® very interesting in many respects and the same time awesome. The low CDD dropout rate, contradicts to what is seen elsewhere. Many CDDs expressed willingness to continue to distribute Mectizan®, irrespective of Government’s failure to pay the CDDs every year as promised, because they consider their service to their communities more valuable than any pay. These need to be systematically documented and to serve as reference materials for promoting community ownership. It is reasoned that if these are real there are lessons to be learn from them. Thus both the evaluation and SWII CDTI implementation teams discussed and agreed that it will be rewarding to conduct one or two operation researches to ascertain the factors driving the zeal in the CDDs to continue to distribute Mectizan and the willingness of the people to continue to take Mectizan®. The questions for the CDD study will include

a. To what extent is their willingness to distribute Mectizan® driven by altruistic motives?

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b. What is the link between CDD willingness to distribute Mectizan® and the current practice where government pays them for their roles every year? c. What is influence of their involvement in other programmes with incentive packages and their willingness to perform their CDD roles?

For the community members the questions may include

a. What are their perceived social and health benefits of taking Mectizan®? b. To what extent is their new interest in Mectizan® driven by the perceived social and health benefits of taking Mectizan®? c. To what extent is the interest in taking Mectizan® driven by external socio- economic factors like government paying the CDDs and the current low or no social or economic demands on the people? d. Will the people continue to want Mectizan® if they are made to play their roles fully and support the CDDs? e. If government withdraws from paying CDDs will the people take full ownership of the programme to an extent that matches their high level of demand for Mectizan® now?

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APPENDIX

I: Programme of Activities in the three day Feedback/Sustainability Plan Development

PROVINCIAL AND DISTRICT LEVEL WORKSHOP PROGRAMME Sustainability of SWII CDTI Project in Cameroon “Feedback”/Planning Meeting

AGENDA DAY ONE Item Activity Time Facilitator 1 Registration of Participants 8.30-9.00 Secretariat/OPC 2 Introduction of Participants 9:00 – 9:05 All 3 Welcome and Opening Remarks 9:50 – 9:15 PDPH 4 Introduction to the workshop; 9:15 – 10:00 Dr. J.C. Okeibunor What are the objectives What is sustainability Methodology for Evaluation 5 Tea Break 10:00 – 10:30 All 6 “Feedback” on achievements, issues and 10:30 – 11:15 lessons from the evaluation on sustainability of CDTI of SWII CDTI Provincial Level District Level Dr. Ekoyol Ewane Health Area (FLHF) Level Ebah Daniel Community Level 7 SWOT Analysis 11.15 – 11.30 Dr. Bambo Ngala 8 Group Work 11.30 – 12.30 Dr. Bambo Ngala Discussions on problems identified and (assisted by other the solutions to these problems using evaluators) SWOT analysis in groups: 1. Planning/Integration 2. Leadership/Monitoring & Supervision 3. Mectizan/Finances 4. Training & HSAM 5. Transport/Human/Coverage 9 Report from Groups & Discussions 12.30 – 13.00 10 LUNCH 13.00 – 14.00 All 11 Roles of the different levels and partners 14.00 – 14.30 Dr. Maduka 12 Steps in Planning for sustainability in 14.30 – 16:00 Dr. Yota Daniel this project and grouping 13 Group work (Development of 16:00 – 16:45 All sustainability plans for Provincial and

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District Levels) 14 General Matters/Announcements 16.45 – 17.00 OPC

DAY TWO Item Activity Time Facilitator 1 Registration of Participant 8:30 – 9:00 Secretariat 2 Review of previous day’s activities 9:00 – 9:05 Rapporteur

3 Introduction to the day’s activities 9:05 – 9:10 Chair to be elected from among the DMOs 4 Resumption of Group Work 9:10 – 10:00 All 5 Tea Break 10:00 – 10:30 All 6 Resumption of Group work 10:30 – 13:00 All 7 LUNCH 13:00 – 14:00 All 8 Presentation of Group Work 14:00 – 15:00 Dr Yota Daniel 9 Group work to incorporate corrections 15:00 – 16:45 All 10 General matters 16:45 – 17:00 OPC

DAY THREE

Item Activity Time Facilitator 1 Registration of Participant 8:30 – 9:00 Secretariat 2 Review of previous day’s activities 9:00 – 9:05 Rapporteur

3 Introduction to the day’s activities 9:05 – 9:10 Chair (to be elected from among the DMOs) 4 Resumption of Group Work 9:10 – 10:00 All 5 Tea Break 10:00 – 10:30 All 6 Way Forward: 10:30 – 12:30 APOC Evaluation Team NGDO Partners NGDO Rep MoH (Provincial & District Levels) National Coord. PDPH 7 Closing Remarks 12.30 – 13:00 PDPH 8 LUNCH 13:00 – 14:00 All 9 General matters/Groups work to tidy up 14:15 – 17:30 Secretariat/All

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II SWOT Analysis South West II CDTI project in the South West Province of Cameroon Level Indicator Strength Weakness Opportunity Threat Project/ Planning • There is an overall • The plan did not vary Systemic Quality Attitude of external Provincial health plan in the for the last three years Improvement (SQI) donor agencies delegation • Some partners do not integrates planning for • The plan has a seem to be clear of all programmes under section on CDTI their role common basket • There is detailed • There is no evidence Sector Wide Approach plan for CDTI of showing the plan to (SWAP) • There is integration other partners in the system • All partners participate in the routine planning • There is a three year sustainability plan (2007-2009) Integration • Support • Systemic Quality Attitude of external activities are Improvement (SQI) donor agencies planned and carried integrates planning for out in an integrated all programmes under manner common basket • This is the Sector Wide Approach practice every year (SWAP) Leadership • Most of the Some high ranking • Coordination Work load and donor leaders are fully officials lack knowledge meetings in the demands aware of the of the workings of the Delegation progress and project • Morning trails problems in the (here project programme • Some of the managers brief leaders demonstrated other members deep thinking about of the

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Level Indicator Strength Weakness Opportunity Threat the problems and delegation on ways of solving the activities of them their • Problems were programme) identified to include – CDDs morale – coverage <65% in some communities – Unreliabl e population – paramete rs Monitoring • Important The Office of the Chief People may not be ready & records are of Unit Supervision, to share the resources of Supervision readily available monitoring and the programme for are of good evaluation provide monitoring and quality opportunity for supervision activities • Staff members coordinated and only supervise integrated monitoring staff at the and supervision District level except on situations where the DMO requests some assistance • Supervision is integrated and targeted to

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Level Indicator Strength Weakness Opportunity Threat increase efficiency • Resources are efficiently used for supervision • As soon as problems are identified they are passed to the DMOs but on request the Delegation assists DMOs Mectizan • The drug Mectizan arrived late in Existence of Southwest Continue single and programme in 2008 Special Fund for Health uniform order of the Delegation Mectizan for the whole handles the country collection and distribution of Mectizan • The system used is effective and uncomplicated • It is dependable and sustainable • There is also no evidence of insufficient supply T&HSAM • Training and • No evidence of • Availability of • Demand for Supervision is increased local radio and motivation by targeted at needs government health slots for media staff

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Level Indicator Strength Weakness Opportunity Threat • Training is financial support different radio • Frequent closure planned and for CDTI station of radio stations executed in implementation in • Availability of efficient manner response to local language • The leadership HSAM broadcasters uses every • Awareness of • General opportunity of CDTI is low assembly of large audience to among the South West sensitize political leaders at Province stakeholders on this level Special Fund for CDTI health • Administrative coordination meeting Finance • Cost of each • Some members of SWAP Donors may not want activity is clearly the leadership are SQI their resource in one spelt out and not clear about basket with others there is evidence what is available Reporting formats for of cost reduction for CDTI donors • The amount • Some members of budgeted is the leadership at within the this level do not expected income know the budget • Staff at this level for the programme has idea of what and the is in the budget contribution of • Project APOC and SSI management is • The APOC aware of finance officer shortfall was not responsive • Funds disbursed to the leadership at for oncho control this level

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Level Indicator Strength Weakness Opportunity Threat from the budget • The delegation at this level are provides nothing efficiently except in managed maintenance of vehicle and other capital equipment • Most of the Govt funds are spent on paying CDDs • No specific and realistic plan to bridge the shortfall • The accounting officer is not aware of residual amounts under budget headings Transport • Vehicles and • No copy of Common pool of Donor pressure & other other equipment previous travelling vehicles Programme leaders Material are readily authorization for Resources available for use of vehicle was CDTI work seen • There is planned • There is no plan routine for replacement of maintenance of vehicle and other vehicle and other equipment equipment • Vehicles and other equipment are maintained with resources from the

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Level Indicator Strength Weakness Opportunity Threat delegation • Transport is properly controlled with trip authorizations • Drivers use log books Human • There is • Project accountant Existence of skilled and • De-motivation of Resources sufficient human is not from the committed staff staff resources government • Instability some • Staff members at service and was staff this level are not even seen • Poor working stable during the environment • Staff members evaluation • Work load are skilled enough to undertake their responsibility at this level • Staff members are highly committed Coverage • Geographical High demand for Co-endemicity of coverage is Mectizan onchocerciasis and loa 100% for the loa past three years Poor motivation of • Therapeutic CDDs coverage is above 65% and is on the increase, ranging

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Level Indicator Strength Weakness Opportunity Threat from 72.9% in 2005 to 76.2% in 2007 District Planning • CDTI is • Plans are routine SQI Same as Provincial integrated into and not targeted SWAP the overall • In one of the written plan for Districts the plan the health district is not integrated • The plans make provision for all key CDTI activities Integration • The various • Activities are not SQI Same as Provincial support activities integrated in one SWAP are planned and of the Districts. implemented in Every programme an integrated carries out its own manner activities • CDTI is also • The reason is that integrated with the team has not Eye care mastered their responsibilities • This means training has not been effective in that health district Leadership • Management • Coordination meetings Non commitment of team at this level Appraisal meetings stakeholders initiate the key Stakeholders meetings De-motivation of staff CDTI activities Work load • The leadership at Poor working this level is environment

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Level Indicator Strength Weakness Opportunity Threat aware of the problems and progress in the project Monitoring • Reporting is • The District team Integrated monitoring Poor means of & within the does not empower and supervision transportation Supervision government the FLHF staff to Donor pressure system handle the Difficult terrain • The resources of problems at their the DHS are level in some used for Health Areas transmitting • Supervision is not reports targeted • As soon as problems are noticed staff at this level take steps to resolve them Mectizan • Mectizan is • In one of the Existence of Provincial Late arrival of Mectizan sufficient in Districts there was drug programme into the country many Districts shortage • The system for • The District did collection of not receive all Mectizan is what was different from requested from the the system used provincial level for other drugs but is uncomplicated and effective T&HSAM • Training • Training is Existence of District Same as provincial

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Level Indicator Strength Weakness Opportunity Threat resources are conducted Appraisal meetings The practice of sending used efficiently routinely every National and wrong health messages • In some Districts year International Days for over the radio by HSAM is • There is no Celebration Traditional healers planned and objective need for Integration of Health No media facilities in carried out in training in most activities some rural areas efficient manner cases Rumours about side • In one of the effects District, it was observed that HSAM activities are planned but inadequately executed • Insufficient advocacy is done towards traditional leaders Finance • The costs of each • The funds are SWAP Same as Province CDTI activity in mainly from SQI the year plan is APOC and SSI Availability of clearly spelt out • Funds from Govt Government Running in a budget are mainly for the Credits at this level • There is payment of CDDs evidence of cost • In one of the reduction Districts it was • Funds are reported that the efficiently funds are usually managed in inadequate and some of the late Districts visited • Budgetary disbursements are

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Level Indicator Strength Weakness Opportunity Threat on the decline • Nothing is done about shortfalls • District is unable to mobilize resources for CDTI • Proper accounting is not considered essential in one of the Districts Transport • The DHS • The vehicles are Existence of elite Refusal of donors & Other maintains the not adequate groups Pressure of donor Material available • There is no Common pool of Resources transport and transport facility vehicles and other other equipment in one of the equipment • Transport is used Districts and managed in • When vehicles an integrated break down staff manner work by trekking long distances • Vehicles are used for personal reasons • No plans for replacement of vehicles and equipment Human • Staff is stable • Staff is dissatisfied Skilled and committed Insufficient staff Resources • Staff members in one of the staff Donor demands on the express Districts staff satisfaction with

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Level Indicator Strength Weakness Opportunity Threat their responsibilities • Staff is committed in some of the Districts Coverage • Geographical • Declining Same as Provincial Same as Provincial coverage is coverage rate in Level Level 100% in the last Eyumojock Health three years District • Therapeutic coverage is >65% and is rising generally • Therapeutic coverage range from an average of 73.7% in 2005 to 75.8% and76.0% in 2006 and 2007 respectively among the Districts visited FLHF Planning • Written work • The Plans do not Same as District Same as District plans exist in show not some of the integrated FLHFs visited implementation of activities in some FLHF • In some FLHFs the staff did not

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Level Indicator Strength Weakness Opportunity Threat know of the existence of a work plan they drew themselves • Plans are routinely drawn • There is an opportunity to train for CDTI along with Polio since the same CDDs are used in both but the staff at this level did not • Staff is waiting for funds to train for CDTI hence commencement of treatment is held up Integration • Staff claims to • There is an Same as District Same as District combine CDTI opportunity to activities with train for CDTI other along with Polio programmes since the same CDDs are used in both but the staff at this level did not • Staff is waiting for funds to train for

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Level Indicator Strength Weakness Opportunity Threat CDTI hence commencement of treatment is held up Leadership • Staff at this level • DMOs initiate Same as District Same as District initiate some training activities • Some of the • Health opinion leaders at management this level are team consider unaware of CDTI CDTI theirs • Where the opinion leaders know they are ignorant of their roles in CDTI Monitoring • Reporting is • In some FLHFs Same as District Same as District & within reports are Supedrvisio government submitted in a n system parallel manner • Problems are using funds from promptly specific managed programmes • Staff in some FLHFs supervise CDDs routinely • Traditional authorities are not involved in problem solving in some Health Areas Mectizan • In most cases • Staff at this level Same as District Same as District Mectizan is not are not allowed to Existence of managed within make requisition community pharmacies

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Level Indicator Strength Weakness Opportunity Threat the same system for drugs as other drugs • Some staff at this but the handling level do not know is efficient and the right formula uncomplicated for ordering drugs • Mectizan is rationed and staff at this level is asked to return to the District for more • Training of CDDs is planned and conducted routinely • No objective need for training • Staff at this level insist on routine training before implementing activities • Traditional leaders are not involved in some Health Areas Finance • In some Health • No budget in most SWAP Same as District Areas, staff use Health Areas visited SQI part of the • The relative Running Credit running credit in contribution of all Health Center Fund running CDTI sources of funding is activities like unknown submission of

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Level Indicator Strength Weakness Opportunity Threat reports

Transport • Transport is • Transport is not Same as District Same as District & Other maintained suitable for Material running CDTI Resources activities at this level • Cost of maintaining vehicles and equipment is not met with health centre funds • Vehicle is used for personal reasons without due control • No plan for replacement Human • Staff at this level Same as District Same as District Resources is stable • Staff is skilled Coverage • Geographical There was a decline in Same as District Same as District coverage is 2006 100% for the In 2007 coverage was also past three years <65% in one of the Health • Therapeutic Areas visited because of coverage is high shortage of Mectizan and rising • Average Therapeutic coverage range

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Level Indicator Strength Weakness Opportunity Threat from 74.9% in 2005 to 79.1% and 75.2% in 2006 and 2007 respectively Communit Planning • CDDs are Some update the registers Health Area appraisal Poor skills of Health y planning and differently from meeting area staff managing their distribution CDTI work efficiently • They make announcements through town criers Leadership • In some • In some Increased interest in Poor awareness of & communities the communities the Mectizan community leaders Ownership leadership takes leaders are not Community Self Poor recognition of the responsibility involved Monitoring traditional authorities • Communities • Health workers Existence of Traditional decide on the decide time for Councils mode of distribution distribution • In some • Some communities communities health worker value Mectizan select CDDs and are happy with it Monitoring • Report gets to • The communities CSM Poor commitment of the FLHF do not provide Appraisal meetings community members promptly transport in many • In some of the cases communities, the

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Level Indicator Strength Weakness Opportunity Threat CDDs collate the reports and submit to the leader of CDDs who then submits to the Chief of Post Obtaining • There is enough • In some there was Existence of Poor ownership & Mectizan every shortage because community pharmacies programme by the Managing year in many the CDDs were communities Mectizan communities not given the • CDDs fetch correct quantity Mectizan for they required their • In some cases the communities CDDs collect Mectizan outside training and no transport is arranged, when they run out of initial supply HSAM • People are Sensitization has not Existence churches, sensitized to take successfully gotten the dialogue structures, Mectizan people to support the socio-cultural groups, CDDs CBOs Some community members demonstrated ignorance about the social and health benefits of Mectizan Financing • In some Nothing is done to Existence of traditional Poor Ownership of the communities support CDDs now councils programme by

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Level Indicator Strength Weakness Opportunity Threat CDDs are Some community leaders Community community members exempted from are not aware of their Development Government policy community work responsibilities Associations motivating CDDS • Some They think government community pays the CDDs so they do leaders are not need to motivate the thinking of ways CDDs of motivating CDDs Human • There are two • In some Abundant youth Demands for motivation Resources CDDs in many communities there Committed CDDs in by CDDs communities is a ratio of 1 CDD some areas • Drop outs are to1000 population Retired teachers and few and easily • Some CDDs nurses replaced threaten to drop • Some CDDs out if they are not have been there paid since inception of the programme • Many CDDs indicated willingness to continue the job for the benefit of their communities even without pay Coverage • Average The trend in coverage is Same as Health Areas Same of Health Areas coverage of the not steady increase in communities some communities visited is 74.6%

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Level Indicator Strength Weakness Opportunity Threat (i.e. >65%) • Average coverage for the communities visited has been consistently >65% in the last 3 years.

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III Solutions to the Weakness and Threats in SWII CDTI

Level Indicator Weakness Suggestion Project/ Planning The plan did not vary for Draw plans with showing needs of Provincial the last three years activities each year Some partners do not Sensitize the partners on their respective seem to be clear of their roles role The book keeping is not Assign a government staff for book by government staff keeping There is no evidence of All partners should participate in showing the sustainability development of sustainability plans plan to other partners Leadership Some high ranking Sensitize all officials on the working of officials lack knowledge the project of the workings of the project Mectizan Mectizan arrived late The NOTF should endevour to order Mectizan twice a year to allow for early supply of Mectizan to projects that distribute between January and June T&HSAM No evidence of increased Intensify sensitization and advocacy government financial support for CDTI implementation in response to HSAM Awareness of CDTI is low among the political leaders at this level Finance Some members of the Increase involvement of key leadership are not clear stakeholders in the planning and about what is available for execution of activities CDTI Some members of the leadership at this level do not know the budget for the programme and the contribution of Govt., APOC and SSI The APOC finance officer Assign a government financial officer for was not responsive to the APOC funds leadership at this level The delegation provides Effectively plan and allocate resources nothing except in for CDTI maintenance of vehicle and other capital

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Level Indicator Weakness Suggestion equipment Most of the Govt. funds are spent on paying CDDs No specific and realistic Train on resource mobilization for plan to bridge the shortfall meeting short falls The accounting officer is Increase involvement of key not aware of residual stakeholders in the planning and amounts under budget execution of activities as well as headings management of funds available for CDTI activities Transport No copy of previous Copies of travel authorizations should be & other travelling authorization for kept in relevant offices at this level Material use of vehicle was seen Resources There is no plan for Make realistic plan and advocate for replacement of vehicle and replacement of vehicle and other other equipment equipment Human Project accountant is not Assign a government staff for book Resources from the government keeping service and was not even seen during the evaluation District Planning Plans are routine and not Draw plans with showing needs of targeted activities each year In one of the Districts the Integrate CDTI activities into the overall plan is not integrated health plan Integration Activities are not Plan activities and implementation integrated in one of the activities in an integrated manner Districts. Every programme carries out its Ensure the training of members of DHS own activities The reason is that the team has not mastered their responsibilities This means training has not been effective in that health district Monitoring The District team does not Train FLHF staff and delegate & empower the FLHF staff responsibilities to them Supervision to handle the problems at their level in some Health Areas Supervision is not targeted Focus supervision on areas with identified weakness

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Level Indicator Weakness Suggestion T&HSAM Training is conducted Identify the needs during supervision and routinely every year yearly appraisals and train accordingly There is no objective need for training in most cases In one of the Districts, it Make sure all the objectives of HSAM was observed that HSAM are met by effectively implementing activities are planned but planned HSAM activities inadequately executed Insufficient advocacy is done towards traditional leaders Finance The funds for field Plan and allocate funding responsibilities activities are mainly from to government and improve on the APOC and SSI. Funds documentation of government from Govt are mainly for contribution for field activities the payment of CDDs and staff salaries In one of the Districts it Train staff to mobilize local resources was reported that the for implementation of field activities funds are usually inadequate and late Budgetary disbursements Advocate for increase budgetary are on the decline disbursements for government sources Nothing is done about Train staff to mobilize local resources shortfalls for implementation of field activities District is unable to Train staff to mobilize local resources mobilize resources for for implementation of field activities CDTI Proper accounting is not Re-orientate DHS staff on the need for considered essential in one accountability of the Districts Transport The vehicles are not Advocate for more vehicles & Other adequate Material There is no transport Advocate for more vehicles Resources facility in most Districts When vehicles break Advocate for more vehicles down staff work by trekking long distances Vehicles are used for There should be a system of control of personal reasons use of vehicles There should be a fee for using vehicle for personal reason No plans for replacement Plan and advocate for replacement of of vehicles and equipment vehicles by government Vehicles are maintained The DHS should ensure the maintenance

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Level Indicator Weakness Suggestion with the personal of vehicles resources of staff in most cases Human Staff is dissatisfied in one Re-orientate staff on the philosophy of Resources of the Districts programme Plan and implement programme to motivate staff Coverage Declining treatment Conduct community meetings to coverage rate in sensitize communities on the need to Eyumojock Health District support CDDs due to withdrawal of Improve supervision of distribution CDDs FLHF Planning The Plans do not show Train FLHF staff on planning and integrated implementation implementation of integrated activities of activities in some FLHFs In some FLHFs the staff Re-orientate staff on the importance of did not know of the using the plans existence of a work plan they drew themselves Plans are routinely drawn Plans of activities should be based on needs There was an opportunity There should be integrated to train for CDTI along implementation of activities at this level with on-going Polio since the same CDDs are used in both but the staff at this level did not in one health Area Staff is waiting for funds to train for CDTI hence commencement of treatment is held up Leadership DMOs initiate training Staff at this level should be empowered to plan and implement activities Some of the opinion Conduct community meetings and leaders at this level are sensitize community leaders on CDTI unaware of CDTI Where the opinion leaders know they are ignorant of their roles in CDTI Monitoring In some FLHFs reports are Re-orientate staff on the principles of & submitted in a parallel integration Supervision manner using funds from specific programmes

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Level Indicator Weakness Suggestion Staff in some FLHFs Supervision should focus on area of need supervise CDDs routinely Traditional authorities are Give feedback and involve traditional not involved in problem authorities in problem solve solving in some Health Areas Mectizan Staff at this level are not Empower staff at this level to make allowed to make requisition for Mectizan tablets they requisition for drugs in need some health areas Some staff at this level do Train staff on the formula for ordering not know the right formula Mectizan for ordering drugs Mectizan is rationed and Supply Mectizan based on needs staff at this level is asked to return to the District for more Training of CDDs is Training should be based on needs planned and conducted routinely No objective need for training Staff at this level insist on routine training before implementing activities Traditional leaders are not Involve community leaders through involved in some Health community meeting and feed backs Areas Finance No budget in most Health Staff should budget for activities at this Areas visited level The relative contribution The relative contribution of all sources of all sources of funding is of funding should be adequately unknown documented Transport Transport is not suitable Plan and advocate for suitable vehicles & Other for running CDTI Material activities at this level Resources Cost of maintaining Maintenance of vehicles and other vehicles and equipment is equipment should be met with FLHF not met with health centre resources funds Vehicle is used for There should be a system of control of personal reasons without use of vehicles due control There should be a fee for using vehicle for personal reason No plan for replacement Plan and advocate for maintenance of

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Level Indicator Weakness Suggestion vehicle and other equipment Coverage There was a decline in Conduct community meetings to 2006 sensitize communities on the need to In 2007 coverage was also support CDDs <65% in one of the Health Improve supervision of distribution Areas visited because of shortage of Mectizan Planning Some update the registers Train CDDs to update census during differently from distribution distribution Leadership In some communities the Involve all community leaders in CDTI & leaders are not involved activities Ownership Health workers decide Empower communities to take decision time for distribution on implementation of CDTI In some communities health worker select CDDs Monitoring The communities do not Communities should be sensitized to provide transport in many support CDDs and to carry out CSM cases Obtaining In some cases the CDDs & collect Mectizan outside Managing training and no transport is Mectizan arranged, when they run out of initial supply HSAM Sensitization has not Engage high powered advocacy team successfully gotten the from the District and Provincial levels to people to support the advocate support for CDDs CDDs Some community Engage high powered advocacy team members demonstrated from the District and Provincial levels to ignorance about the social advocate support for CDDs and health benefits of Mectizan Financing Nothing is done to support Engage high powered advocacy team CDDs now from the District and Provincial levels to advocate support for CDDs Some community leaders Engage high powered advocacy team are not aware of their from the District and Provincial levels to responsibilities advocate support for CDDs They think government Engage high powered advocacy team pays the CDDs so they do from the District and Provincial levels to not need to motivate the advocate support for CDDs CDDs Human In some communities Communities should be sensitized to

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Level Indicator Weakness Suggestion Resources there is a ratio of 1 CDD increase the number of CDDS to1000 population Some CDDs threaten to CDDs should be sensitized on the need drop out if they are not to help their communities paid Engage high powered advocacy team from the District and Provincial levels to advocate support for CDDs Coverage The trend in coverage is Conduct community meetings to not steady increase in sensitize communities on the need to some communities support CDDs Improve supervision of distribution

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IV Persons Interviewed at the SWII Evaluation

NATIONAL LEVEL/ PARTNERS S/No FULL NAME TITLE 1 Hendji Michael NOCP (Finance Officer) 2 Dr. Rosa Befidi SSI (Country Representative) 3 Cyril Evini SSI (Program Manager) 4 Ngole Roland SSI/Eye Care (Project Fin. Officer) 5 Wilson Arrey Etta SSI (Fin Officer)

PROVINCIAL LEVEL S/No FULL NAME TITLE 1 Eyeya Zanga Louis Governor 2 Dr. Mafany Njie PDPH 3 Dr. M. Ako-Arrey Provincial Chief of Unit (Supervision/Monitoring/Evaluation) 4 Mr. Oponde Peter OPC 5 Mr. ilambo Pius Mokeyo Provincial Chief of Service (General Affairs) 6 Mrs Ula Abunaw Manager, SW Provincial Special Fund for Health (SWPSFH)

DISTRICT LEVEL S/No FULL NAME TITLE 1. Dr. Wamba Gaston DMO, Fontem 2. Njilem Joseph CBH, Fontem 3. Fongam Zacharia CBAF, Fontem 4. Ekoume Juines-Eric 1st Asst to SDO, Fontem 5. Dr. Emalieu Toko Joseph DMO, Eyumujock 6. Laluh William Agbor District Chairman 7. Dr Atembeh DMO, Ekondo Titi 8. Pa Luc CBH, Ekondo Titi 9. Madam Kule CBH, Ekondo Titi 10. Rose Wihe CBAF, Ekondo Titi 11. Njocha Romanus Admin. Personnel, Ekondo Titi 12. Ekie Ernestin Leprosy Supervisor, Ekondo Titi

HEALTH AREA (FLHF) Staff Interviewed

S/No FULL NAME TITLE PLACE 1) Achuo Jonas Chief of Post Takwai Health Centre 2) Ajiawung Athanasius Chief of Post Fotabong Health Centre 3) Asanji james Noubila Chief of Post Afap Health Centre 4) Tebetah Harry Arrey Chief of Post Kembong 5) Ilambo Cornlius Chief of Post Ekondo Titi

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6) Mejame Ruth Nurse Ekondo Titi 7) Ndive Clara Midwife Ekondo Titi 8) Enow Pauline Nurse Ekondo Titi 9) Eta Justice Lab. Tech Ekondo Titi 10) Bau Patience Pharmacy Attendant Ekondo Titi 11) Emilia Oben Ward Maid Ekondo Titi 12) Okolle Peter Iloemeje Chief of Post Illor Health Centre 13) Airo Mispa Pharmacy Attendant Illor health Centre

COMMUNITY LEADERS

S/no FULL NAME TITLE 1. Fongang Thomas Ashu Rep. Village Leader, Takwai 2. Enow Nyoh Comm Leader, Mamboh 3. Bisam Max Comm leader, Ebensuck 4. Chief Joseph Fotembe Comm. Leader, Eselewon 1 5. Acheng Njang Anthony Akawung Chair, HA Health Committee 6. Arrey Arrey Peter Chief, Afap Community 7. Etah Obi Takar Raphael Mbakang 8. Nju Tabot Thomas Ossing 9. Agbor Takang Harry Nfuni 10. Chief Moki Augustine Chief, Dibonda

COMMUNITY DIRECTED DISTRIBUTORS S/no FULL NAME TITLE 1. Enow Wilson Ashu CDD, Takwai 2. Enoch Simon CDD, Ebensuck 3. James Nkengasong CDD, Belap 4. Athanacious Achankeng CDD, Eselewon 1 5. Philip Aminkeng CDD, Eselewon 2 6. Takang CDD, Afap 7. Obi Ernest Asau CDD, Mbakang 8. Besong Eric CDD, Ossing 9. Agbor Maka CDD, Ossing 10. Takang Andrew CDD, Nfuni 11. Akama Nangiya CDD, Dibonda

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V LIST OF DOCUMENTS OBSERVED

1. Provincial Level - Provincial Comprehensive Health Plan 2007 and 2008 - Provincial Budget Document 2006-2008 - SWII Three Year Sustainability Work Plan for CDTI 2007-2009 - Minutes of Planning Meetings - SWII Mectizan Treatment Coverage 2005-2007 - Log book for the project Vehicle

2. District Level - Comprehensive health plan 2007 and 2008 - Payment Voucher (justification) 2005, 2006, 2007 - Three Year Action Plan for CDTI 2007-2009 - Work plan for CDTI - Budget 2005, 2006, 2007 - CDTI supervisory check list - Mectizan requisition form - Expenditure authorization form. - Training manual

3. FLHF Level - Three year CDTI work plan 2007-2009 - Mectizan distribution summary sheet 2005-2007 - CDDs training attendance list 2003 - CDTI supervision checklist - Mectizan Register - CDTI training manual (practical guide for trainers)

4. Community Level. - Community Register - Community Treatment Summary - Measuring Stick

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VI ADDRESSES FOR EVALUATION TEAM MEMBERS

SOUTHWEST II CDTI PROJECT

NAME ADDRESS Dr Bambo Ngala Emmanuel Nkambe Health District BP 1842 Nkambe North West Province Republic of Cameroon Cell Phone +237 77660654 E-mail: [email protected]

Dr. Chinyere Maduka Ministry of Health Public Health Department Anambra State Nigeria [email protected] Tel +234 8073451166 Dr. Yota Daniel Tubah Health District Po Box 6 Bambili Republic of Cameroon Tel +237 75 29 25 40 E-mail: [email protected]

Dr. Ekoyol Ewane Germaine Ministry of public Health Department of disease control Yaoundé Republic of Cameroon E mail: [email protected] Tel;+ 237 77 67 27 42 Mr. Ebah Daniel Ministry of Public Health CDA/MSP/SG Yaoundẻ Tel +237 77 66 52 81 E-mail: [email protected]

Dr. Joseph C. Okeibunor Department of Sociology/Anthropology University of Nigeria, Nsukka Enugu State Nigeria. Cell: +2348043180351 e-mail: [email protected]

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VII Minutes of the Feed back/Sustainability Planning Workshop (Minutes taken by Programme staff)

SUSTAINABILITY OF SWII CDTI PROJECT IN CAMEROON: FEEDBACK / PLANNING MEETING. DAY ONE REPORT: 23-04-08

The meeting started at 9:30am with the registration of participants. An opening prayer was given by one of the participants. This was immediately followed by a welcome address made by the delegate’s representative and introduction of participants.

Dr. Joseph Okeibunor, the leader of the evaluation team made a presentation on the methodology used for the evaluation. He started by noting that this project was first evaluated in 2003 and this is a re-evaluation which has the aim of assessing the extent to which improvements have been achieved in the project following the findings and recommendations of 2003 evaluation.

He specifically listed the objectives of this workshop to include A) giving feedback on the evaluation B) discussing the results C) developing a five year sustainability plan

For the evaluation, the team, made up of two external and four internal members who went to three Health Districts, six Health Areas and Twelve communities. He presented an overview of the results showing that generally the project has made significant improvement over the 2003 results. This was followed by a coffee break.

The presentation continued with Dr. Ewane on the feedback, on achievement issues and lessons from the evaluation of sustainability of CDTI SWII which was drawn from four levels. - The provincial level - The district level - The health area (FLHF) level - The community level Aspects of sustainability identified. A comparative performance on all the indicators in the entire project was done with finance, transport and other material resources for CDTI since some partners are withdrawing their funds. The presentation was followed by some reactions from the participants on the shortages of mectizan in some Health areas and communities, calculation of the next year’s need of mectizan in the health areas and communities and the issue of sustainability by the community since the partners are gradually withdrawing their funds. Health area committee members do not pass health information to their communities and some CDD’s trained collect mectizan and keep due to lack of payment for the previous years. These reactions were addressed by the evaluators and programmed to be included in the plan. Meanwhile the formula for calculating the need for mectizan for the next distribution was given as follows 1. 1/n = total population Yn-1=total population 2. ATO=UTC=84% of total population 3. Need = UTC X 3 – left over of the previous year.

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Despite the shortcoming Dr. Ikeibunor expressed the willingness of the CDDs to continue distribution and the community to take mectizan as discovered during their evaluation in the field.

The next facilitator Dr. Bambo presented SWOT Analysis with group discussions on problems identified and solutions to indicators of sustainability which included leadership monitoring and supervision - Planning / integration - mectizan / finance - Training and HSAM - Transport, Human and Coverage

Lunch break was at 4:00pm After the lunch the role of the different levels and partners were analyzed and steps involved in planning for sustainability in the project enumerated by Dr. Maduka and Dr. Yota respectively. This was concluded with the criteria for further APOC support after five years. Day’s one activities ended at 5:30 pm.

Reporters: Ayamba Helen Njilem Joseph

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MINUTES ON DAY II (24th April, 2008) SUSTAINABILITY PLANNING MEETING ON CDTI ACTIVITIES FOR YEAR 9 (CDTI SWII)

Moderator: Dr. Yota Daniel Agenda: Presentation of Group work of produced planned activities at different levels of the Health System.

The presentation started at about 15:15 with the Provincial team taking the lead. Mr. YINOU Ernest who is also the chief of planning of programs in the Provincial Delegation of Public Health for the South west presented the plan of activities for the provincial level.

This was followed by presentations from some districts which were as follows: - Dr. Bamulu for the Mamfe Health District Dr. Dogmo from Bakassi Health District Dr. Ndoko from Eyumojock Health District and Dr. Eric Wanneh from Wabane Health District respectively.

Ten minutes were given for the presentation for each group and ten minutes for questions, opinions and suggestions and criticisms to the audience to react.

During the periods for reactions, it was realized that there was a mix up between means of verification and expected out comes. To this, one of the evaluators explained the difference between the two points and advised that for a full plan to be made, the expected outcome should tie up with the activities carried out, in order to meet up with the objectives.

Also it was said that certain points should be spelt out or put into sub points, rather than doing general costing of these items.

It was also pointed out during the presentations that no financial presentations were made by any of the presenting groups. But later, it was attributed to time constraint and that by the next day all groups must have finished with their finance presentation.

Also amongst the presenters, Dr. Ako Arrey from the provincial delegation of public health for the South West Praised the newly created Health Districts like Bakassi, Wabane and Eyumojock for their good presentations and Eyumojock especially for bringing out the problem of Oguram which is very peculiar in that district.

The presentations ended at 5; 20pm while Mr. Oponde gave the closing statement, which is talking about the workload, insisting on an early start of work the next day and encouraging the other districts who were behind the scheduled work to speed up and finish up their work so that presentations can be finalized on the 3rd and last day of the program. He then wished everybody a goodnight and to burn their midnight candles.

Reporter: IKOE Cyriel Okolie DAY III (25th April 28, 2008)

At 8am the participants reconvened and continued with the elaboration of their Sustainability plans. This exercise was briefly stopped at 10 am for coffee break of 30 minutes. On

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resumption from coffee break, the group work of day one which was not completed had to be completed by all the participants. Solutions to weaknesses identified during the evaluation were addressed by all in a participatory manner.

At 1.30pm, the Provincial Delegate of Public Health called in to officially close the workshop. After his closing statement, he advised the participants to continue and complete their plans. He apologized he had to do the closing a bit earlier because of other pressing official issues. (Copy of closing remarks by the delegate is attached). The participants continued with drawing of their plans. After completion of this exercise, the following concluded the days’ activities.

WAY FORWARD

The next item on the agenda was the way forward. At this level, the different bodies were required to give possible ways and means for which they think will help in the continuation of the project.

The APOC representative was asked to speak first. He first of all appreciated the commitment and total involvement of all participants during the meeting. He then advanced the points: - 1. That he was going to make the necessary recommendations he finds fit for further support from APOC. 2. Also new capital equipment and capacity building from APOC.

SIGHTSAVERS INTERNATIONAL

The country representative promised that 1. Sights savers will continue too fund the program even if APOC withdraws. 2. That sight savers will support mainly indispensable activities. 3. Organize a training session to advocate for funding (resource mobilization workshop) due to gap in funding. 4. Provide funds for activities for the next 3 years, and that the funds will increase as activities increases.

NOTF

The representative for NOTF was very better on the fact that financial issues were not properly handled. He made the following points clear: 1. That more efforts are put in financial reports and it should be of quality. 2. Justifications on all activities should be done 3. Money will be sent on time provided justifications are sent on time. At this point Mr. Oponde, the Provincial Coordinator for CDTI SWII added that Districts will have money for eye care (ten thousands francs per health area (10,000 FRS per health area, 5,000 FRS per health area for carrying out activities for eye care)

At this stage the Team leader Dr Joseph asked each of the district medical officers to give their own way forward.

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DISTRICT OFFICER FOR MUNDEMBA (DMO)

The district medical officer for Mundemba started by saying that, he is going to improve on his planning strategy. He then pleaded that, the partners should continue to help so too the Ministry of Public Health for he has a committed staff to do the work.

DMO EYUMOJOCK

The DMO for Eyumojock said he was going to transmit all the information from the meeting to the health areas and the community, and he hope to mobilize and sensitize the community on CDTI. He then pleaded that all support be given him.

DMO Wabane

The DMO for Wabane said most of the actors do not know the philosophy of the program. So partners especially provincial Delegation of Public Health should help support on sensitization program. He further explained that he has newly recruited personnel but they do not experience and he lacked material resources. He also acknowledged the fact that he has learned a lot on planification

DMO Ekondo Titi

The DMO for Ekondo Titi affirmed that he has understood the necessity of planning from Evaluator’s visit so well. He has also been trained on drawing realistic plans of action and to execute them. He made mentioned that the Community is aware of the program and taking ownership except Kombe Baluwe. He promised that he is going to carrying out intensive HSAM in this area. He promised to improve in the next year’s program.

DMO Fontem

The DMO for Fontem promised that he was going to Orientate his staff on what programs is supposed to be, reinforce CDD motivation, and improve on HSAM to have good coverage. He then pleaded to the Province to help orientate old staff because it is difficult to control them.

DMO Akwaya

The DMO for Akwaya said, his main challenge is to mobilize and get the community leaders to own the program and to explore the political leaders. He said ten communities gave support to CDDs. He went further to explain that he had coverage of 72-75% within the last two years and he will make efforts to maintain and improve on the results. By doing this he is going to involve all the staff in the activities. He also said; improve in the roads will help a lot.

DMO Mamfe

The DMO of mamfe said the provision of means of movement has helped in an improvement of results thanks to EPI. He also congratulated the OPC SWII for always being present in the field to solve problems and giving guides. He made mention of the fact that the Divisional Officer of Mamfe always take Mectizan in the field on National days and this has boost people to take

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Mectizan. He said one of the communities (Kadifou) has a very difficult settlement hence poor coverage. He promised to improve on his results and also pleaded that means of transport be provided.

DMO Bakassi

The DMO for Bakassi acknowledged the fact that the meeting has helped to improve on his skills especially as he has just been newly recruited and posted to the new Health District. He said he is now able to draw plans hence ease evaluation. He pledged that Bakassi be visited he the next Evaluation exercise.

The Provincial Chief of Unit for Supervision Monitoring and Evaluation appreciated the fact that every DMO was given the opportunity this time to say something. She said, acknowledgements are very important. He acknowledged that the forum has made people to know that they have been joking when it comes to planning.

She added that Provincial Delegation of Public Health (PDPH) will always assist but will not exceed the previous amounts. She reminded the participant that in the previous meeting of CDTI the SWOT analysis was there so as for them to know where they were going. The forum has also helped people to understand what they did for planning.

She emphasized that people should stop thinking that they are working for other people and that work should be taken as an individuals own work, and that plans must be implemented.

She went further saying that the DMOs should make their request clear to the Delegation and their needs will be provided.

She concluded by advising that targeted activities should be done and not routine activities and individuals should evaluate themselves first and not only wait to be evaluated.

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VIII SPEECH DELIVERED BY THE PROVINCIAL DELEGATE OF PUBLIC HEALTH DR. MAFANY NJIE MARTIN, ON THE OCCASION OF THE EVALUATION OF SUSTAINABILITY OF SW II CDTI PROJECT IN CAMEROON.

Date: 25/04/2008 Place: Conference Hall, Delegation of Public Health Buea.

I stand here to thank the External Evaluators here present, from APOC, Ministry of Public Health, Official of NGO, SSI team, and other evaluators for a job well done.

The Province is happy that evaluators came, have seen and have recommended. All we have to say is that certain indicators which have appeared again as hiccups need to be addressed to as fundamental problems of our health care delivery system. If we take another project like EPI, Roll Back Malaria, TB, the question concerning the account might be the same. The problem of job description might be the same. The problem of implication of the Delegation, and appropriation of all these vertical projects might be the same.

The government of Cameroon seeing all these, decided on SWAP, (Sector Wide Approach) in having a common basket for planning, execution, evaluation adaption of all projects. District Development plans draft (0) have just been realized, for all projects. They are being studied and in two weeks form now, the provincial conference to harmonize these plans will take place.

Hopefully as we are seeing the French Agency for Development, the German Agency for Development (KFW), World Bank mission, and other partners, WHO, UNICEF etc who signed these convention 2005, in Kribi, for the Sector Wide Approach, willing to reinforced its take off in 2009, and hoping that parliament will have the bill go through.

For now, we think, we are still indebted to APOC, SSI, Ministry of Public Health etc, for vehicles, motorcycles, heavy exploitation, materials like computers to name a few and the problem of payment of CDDs addressed to.

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All of you have worked so hard to come up with plans which I believe reflect this vision. While wishing those who are leaving today safe return, those who have some days to enjoy our country site, you are welcomed. May God bless all of you. I declare this evaluation of SW II closed.

- Long live SWII CDTI project - Long live international co-operation - Long live the Ministry of Public Health - Long live the Republic of Cameroon with it illustrious President: President Paul Biya

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IX Attendance List at the Feedback/Planning Workshop

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